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TEX TB OOK
OF
Veterinary
Diagnostic
Radiology
TEXTBOOK
OF
Veterinary
Diagnostic
Radiology
FOU R THE D ITIO N

Donald E. Thrall, DVM, PhD

Professorof Radiology
Collegeof VeterinaryMedicine
North Carolina State University
Raleigh,North Carolina

SAUNDERS
An Imlirint of Elsevier
SAUNDERS
An Imprint of Elsevier
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i
't, ^;
f li
i I r,0t- I

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Library of Congress Cataloging-in'PublicationData

Textbookoi veterinary diagnosticradiology/ [edited by] Donald E. Thrall.---4thed'

p. ; cm.

referencesand index.
Includesbibliographical

ISBN-13:978-0-7216-8820-6 ISBN-10: 0-7216-8820-9

1. Veterinaryradiography. l. Thrall,DonaldE.
IDNLM: 1. Radiography-veterinary. SF 757.8T355 20021

5F757.8.1482OO2 636.089'0757-dc21

DNLM/DLC 2001042608

ISBN- I 3: 97I -0 -7216-8820-6

ISBN-10: 0-7276-8820-9

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TEXTBOOK OF VETERINARY DIAGNOSTIC RADIOLOGY, Fourth Edition

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 CONTRIBUTORS
Graeme Allan, BVSc, MYSc, Diplomate ACVR, FACVSc
-\djunct Professor,
Facultyof VeterinaryScience,
Universityof
Svdney,Sydney;ConsultantVeterinaryRadiologist,Veterinary
ImagingAssociates, Newtown,Australia
RadiographicSigns of Joint Disease
Robert J. Bahr, DVM, Diplomate ACVR
Associate
Professorof Veterinary
Radiology;
SectionChief,
Radiology,BorenVeterinaryMedicalTeachingHospital,Collegeof
VeterinaryMedicine,OklahomaStateUniversity,Stillwater,
Oklahoma
The ThoracicWall; The Heart and Great Vessels
Debra K. Baird, DVM, PhD, Diplomate ACVR
ClinicalAssistant
Professor,Diagnostic
Imaging,Purdue
University,WestLafayette,Indiana
The Tarsus
Don L. Barber, DVM, MS, Diplomate ACVR
Professorand Head,Departmentof SmallAnimal Clinical
Sciences,
Virginia-Maryland Regional
Collegeof Veterinary
Medicine,Virginia Tech,Blacksburg,
Virginia
The PeritonealSpace;The Stomach
Clifford R. Berry, DVM, Diplomate ACVR
AdjunctAssociateProfessorof Radiology,Universityof Tennessee
Collegeof VeterinaryMedicine,Knoxville,Tennessee; Staff
Radiologist,VeterinarySpecialistCenter,Maitland,Florida
PhysicalPrinciplesof Computed Tomographyand
Magnetic Resonancelmaging; Introductionto
RadiographicInterpretation;InterpretationParadigms
for the Axial Skeleton-Small and Large Animal;
InterpretationParadigmsfor the Appendicular
Skeleton-Canine and Feline;InterpretationParadigms
for the AppendicularSkeleton-Equine; Interpretation
Paradigmsfor the Small Animal Thorax; Interpretation
Paradigmsfor the Abdomen-Canine and Feline
Darryl N. Biery, DVM, Diplomate ACVR
Professorof Radiology,Schoolof VeterinaryMedicine,University
of Pennsylvania,
Philadelphia,Pennsylvania
The Large Bowel
f. Gregg Boring DVM, MS, Diplomate ACVR
Professor,Mississippi Collegeof Veterinary
StateUniversity,
\ledicine,Mississippi
State,Mississippi
The Equine Carpus
William Tod Drost, DVM, Diplomate ACVR
,\ssistantProfessorof Radiology,Collegeof VeterinaryMedicine,
The Ohio StateUniversity,Columbus,Ohio
Basic Ultrasound Physics
C. S. Farrow, DVM, Diplomate ACVR
Professorof MedicalImaging,WesternCollegeof Veterinary
\ledicine,Universityof Saskatchewan,
Saskatoon, Saskatchewan,
Canada
Larynx,Pharynx,and Proximal Airway; The Equine Lung
Daniel A. Feeney,DVM, MS, Diplomate ACVR
Professorof Radiology,Collegeof VeterinaryMedicine,University
of Minnesota,St.Paul,Minnesota
The Kidneysand Ureters;The Uterus, Ovaries,and
Testes
Lisa J. Forrest, VMD, Diplomate ACVR
ClinicalAssociateProfessor,
Universityof Wisconsin-Madison,
Schoolof VeterinaryMedicine,Madison,Wisconsin
The Cranial and Nasal Cavities-Canine and Feline
Patrick R. Gavin, DVM, PhD, Diplomate ACVR
Professor,
Radiology,VeterinaryClinicalSciences,
Collegeof
VeterinaryMedicine,WashingtonStateUniversity,Puilman,
Washinston
The Equine VertebralColumn
|ohn P. Graham, MVB, MRCVS, MSc, Diplomate ACVR
AssistantProfessor,
Universityof Florida,Collegeof Veterinary
Medicine,Gainesville,
Florida
The Liver and Spleen
Gary R. fohnston, DVM, Diplomate ACVR
WesternUniversityof HealthSciences,
Collegeof Veterinary
Medicine,Pomona, Calilornia
The Kidneysand Ureters;The Uterus, Ovaries,and
Testes
Stephen K. Knellen DVM, MS, Diplomate ACVR
AssociateProfessor, SectionChief-Imaging/RadiationTherapy,
Universityof Illinois, Urbana,Illinois
The Metacarpus and Metatarsus; The Larynx, Pharynx,
and Trachea
Linda |. Konde, DVM, Diplomate ACVR
VeterinaryRadiologist,DiagnosticImaging,PC, Aurora,Colorado
Diseasesof the lmmature Skeleton
Christopher R. Lamb, MA, VetMB, Diplomate ACVR
SeniorLecturerin Radiology,The RoyalVeterinaryCollege,
Universityof London,London,England
-
The C ani neand Fel i neLung
Iimmy C. Lattimer, DVM, MS, Diplomate ACVR
AssociateProfessor,
Departmento{ VeterinaryMedicineand
Surgery,Collegeof VeterinaryMedicineand Surgery,Universityof
Missouri-Columbia;SectionHead-Radiology, Veterinary /
MedicalTeachingHospital,Universityof Missouri,Columbia,
Missouri
Equine Nasal Passagesand Sinuses;The ProstateGland
John M. Losonsky, DVM, MS, Diplomate ACVR
FormerlyAssociate Professor,
Collegeof Veterinary
Medicine,
Universityof Illinois,Urbana,Illinois
The PulmonaryVasculature
t,i CO NT RI B UT O R S
Nanry E. Love, DYM, Diplomate ACVR
AssociateProfessorof Radiology,North CarolinaStateUniversity,
Raleigh,North Carolina
Introductionto RadiographicInterpretation;
InterpretationParadigmsfor the Axial Skeleton-Small
and Large Animal; InterpretationParadigmsfor the
AppendicularSkeleton-Canine and Feline;
InterpretationParadigmsfor the Appendicular
Skeleton-Equine; lnterpretation Paradigmsfor the
Small Animal Thorax; InterpretationParadigmsfor the
Abdomen-Canine and Feline
Mary B. Mahaffey, DVM, MS, Diplomate ACVR
Professorof RadiologyDepartmentof Anatomyand Radiology,
The Universityof Georgia,Athens,Georgia
The Stifle; The PeritonealSpace;The Stomach
Sally K. Mitchell, DVM' Diplomate ACVR
Departmentof SmallAnimal Clinical
AssistantProfessor,
Sciences, Collegeof VeterinaryMedicine,
Universityof Tennessee,
Knoxville,Tennessee
FractureHealing and Complications
Lisa Neuwirth, DVM, MS, Diplomate ACVR
Radiology,LargeAnimal Medicine,The
AssociateProfessor,
Universityof Georgia,Collegeof VeterinaryMedicine,Athens,
Georgia
The Equine Carpus
Susan M. Newell, DVM, MS' Diplomate ACVR
EastGreenwich,
Radiologist,OceanStateVeterinarySpecialists,
RhodeIsland
The Liver and Spleen
Marc Papageorges,DVM, MS' PhD' Diplomate ACVR
President,VeterinaryDiagnosticImagingand Cy'topathology,
Clackamas, Oregon
Visual Perceptionand RadiographicInterpretation
Richard D. Park, DVM, PhD, Diplomate ACVR
Departmentof Radiological
Professor, HealthSciences, Collegeof
VeterinaryMedicineand BiomedicalSciences, ColoradoState
University;Head,Sectionof Radiology,VeterinaryTeaching
Hospital,ColoradoStateUniversity,Fort Collins,Colorado
The Diaphragm;The Urinary Bladder
Robert D. Pechman, Jr., DVM, Diplomate ACVR
Professorof VeterinaryRadiology,Schoolof VeterinaryMedicine,
LouisianaStateUniversity,BatonRouge,Louisiana
The Urethra
Elizabeth A. Riedesel, DVM' Diplomate ACVR
AssociateProfessor, Collegeof
VeterinaryClinicalSciences,
VeterinaryMedicine;SectionLeader-Radiology,Veterinary
TeachingHospital,Iowa StateUniversity,Ames,Iowa
The Phalanges;The Small Bowel
Charles R. Root, DVM, MS' Diplomate ACVR
Owner,AnimalMedicalImaging,PLLC,Redmond, Washington
The ThoracicWall; The Heart and Great Vessels;
Abdominal Masses
Ronald D. Sande, DVM, MS, PhD, Diplomate ACVR
Professor,
Veterinary Washington
ClinicalSciences, State
University,Pullman,Washington
The Metacarpophalangeal(Metatarsophalangeal)
Articulation;The PleuralSpace
fames E. Smallwood, DVM, MS
Alumni DistinguishedProfessorof Aratomy,Collegeof Veterinary
Medicine,North CarolinaStateUniversity,Raleigh,North
Carolina
RadiographicAnatomy of the Dog and Horse
Kathy A. Spaulding DVM, Diplomate ACVR
Associate
Professor,
Collegeof Veterinary Medicine,North
CarolinaStateUniversity,Raleigh,North Carolina
RadiographicAnatomy of the Dog and Horse
Donald E. Thrall, DVM, PhD, Diplomate ACVR
Professorof Radiology,Collegeof VeterinaryMedicine,North
CarolinaStateUniversity,Raleigh,North Carolina
RadiationPhysics,RadiationProtection,and Darkroom
Theory; Introductionto RadiographicInterpretation;
Ganineand FelineIntervertebralDisc Disease,
Myelography,and Spinal Cord Disease;Interpretation
Paradigmsfor the AppendicularSkeleton-Canine and
Feline;Bone Tumors Versus Bone Infections;
InterpretationParadigmsfor the Appendicular
Skeleton-Equine; InterpretationParadigmsfor the
Small Animal Thorax; The Mediastinum;The Pleural
Space
Robert L. Toal, DVM, MS, Diplomate ACVR
DirectoqDiagnosticImagingCenter,SouthPaws
Veterinary
ReferralCenter,Springfield,Virginia
FractureHealing and Complications;The NavicularBone
Russell L. Tucker, DVM, Diplomate ACVR
AssociateProfessor,
Radiology,Veterinary
ClinicalSciences,
Collegeof VeterinaryMedicine,WashingtonStateUniversity,
Pullman,Washington
The Equine VertebralColumn; The Metacarpophalangeal
(Metatarsophalangeal) Articulation
Michael A. Walker, DVM, Diplomate ACVR
Professor,
Collegeof VeterinaryMedicine,TexasA & M
University,CollegeStation,Texas
The Vertebrae-Canine and Feline
Barbara )ean Watrous, DVM, Diplomate ACVR
Professor,
Radiology,OregonStateUniversiryVeterinaryTeaching
Hospital;Professor,
Radiology,OregonStateUniversity,Corvallis,
Oregon
The Esophagus
William R. Widmer, DVM, MS, Diplomate ACVR
Professor
of Diagnostic
Imaging,Schoolof Veterinary
Medicine,
PurdueUniversity,WestLafayette,Indiana
RadiationPhysics,RadiationProtection,and Darkroom
Theory; Canine and FelinelntervertebralDisc Disease,
Myelography,and Spinal Cord Disease
Erik R. Wisner, DVM, Diplomate ACVR
Associate
Professor,
Departmentof Surgicaland Radiological
Sciences,
Schoolof Veterinary
Medicine,Universityof California,
Davis,California
Diseasesof the lmmature Skeleton
Robert H. Wrigley, BVSc, MS, DVR, MRCVS, Diplomate
ACVR
Professor,
Departmentof Radiological Collegeof
Sciences,
VeterinaryMedicine and BiomedicalSciences,Colorado State
University; Head, Ultrasonography, Veterinary TeachingHospital,
Colorado State University, Fort Collins, Colorado
The Urinary Bladder
 PRE FA CTEO T H EFO URT H
EDI T I O N
The primary purpose of this book is to serve as an instructional
aid. The book is also useful for assistingwith patient management,
but its main mission is to facilitate the learning of radiology. As
such, most of the modifications contained in this fourth edition
were aimed at that purpose. Vaiuable features of previous editions,
such as the self-assessmentquestions and the atlas of normal
anatomy, have been retained.
Al1 chaptershave been revised extensively.New chapterson basic
interpretive principles have been included. A chapter on general
interpretive principles is again included, but five new chapters
address specifics of interpretation relating to the axial skeleton in
sma1l and large animals, the appendicular skeleton in small and
large animals, and the thorax and abdomen in sma1l animals.
Details of positioning, specific anatomic features of the body part
in question, methods of radiographic viewing, and assessmentand
applications of specialized imaging modalities are some of the
topics coveredin these new chapters.The major purpose of these
new chapters is to provide a framework for interpretation that can
be built upon when assessing the more specificinformation pro-
vided in other chapters.
The amount of coveragedevoted to diagnostic ultrasound in this
textbook has fluctuated since the first edition was oublished. In the
last edition, information on sonographicimaging was minimized.
However, ultrasound imaging has become such an ingrained part
of veterinary practice that I felt it was important to increase the
amount of information on this modality. Thus, a new chapter on
the physics of ultrasound imaging has been prepared, and the
description of the sonographicfeaturesof many common abnor-
malities has been enhanced in manv other chaoters.
The basiso[ interpretationused in thjs textbook remainscen-
tered on description of radiographic abnormalities in terms of
roentgen signs-changes in size, shape, opacity, number, and mar-
gination. I believe that students who have a firm understanding of
roentgen sign description will be less inclined to make errors
by jumping immediately to a diagnosis rather than thoroughly
considering radiographic changesin an orderly and efficient man-
ner. In previous editions, even with the roentgen sign approach,
there was some variability with regard to chapter structure-some
chapters were organized according to abnormality and some ac-
cording to roentgen signs. In this new edition, chaptersare pnmar-
ily arranged based on the most common abnormalities affecting
that particular system,with abnormalities being described in terms
of roentgen signs. This standardization will increase the cohesive-
ness of the book and reinforce the value of the roentgen sign
approach while, at the same time, emphasizing the most common
abnormalities encountered in patients.
Thanks are extended to all who have used previous editions of
this work and to thosewho havepointed out;rrors or omissions,
thereby allowing this edition to be what I believe is the best one
yet. Finally, I think it would be impossible for one person to
prepare a comprehensive textbook of veterinary radiology. I am
fortunate to have so many talented authors take time from their
busy schedules to prepare material for this book. Several new
authors have contributed to this fourth edition, and many familiar
names are again found as contributors. The expertise of this team
heightens the quality of the information contained on these pages,
and I am honored by their participation.
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- !
Physics and Principles of Interpretation
cHAprER
1 Radiation Physics, Radiation
Protec t ion, and Dar k r oom Theor y . . . . . . . . . 1
Don aldE.Thr all
WilliamR.W idm er
cNAprER
2 Basic Ultrasound Physics
WilliamTodDrost
cHAprER
3 Physical Principles of Computed
Tomography and Magnetic
Re so nanc e lm aging
CliffordR. Berry
cHAprER
4 Visual Perception and Radiographic
Inte r pr et at ion . . . .
MarcPapageorges
cHAprER
5 Introduction to Radiographic
Inte r pr et at ion. . . .
CliffordR. Berrv
NancvE. Love
Don aldE.Thr all
craprrn13 Diseasesof the lmmature Skeleton . . . . . . 146
E ri k R . Wi sner
Li ndaJ. K onde
crapren
14 FractureH eal i ngand C ompl i cat ions. . . . . 161
Robert L. Toal
S al l y K . Mi tchel l
cH,cpruR
15 Bone Tumors Versus Bone Infections . . . . 179
. . 20
D onal d E . Thral l
crnpreR
16 RadiographicSigns of Joint Disease. . . . . 187
GraemeA l l an
. ..... . .28
lll;l6x t i*jlirv;ll1ile:lr:111el:611l1lll*X:lt:;ltllll;loX3lilllg,,.
o^1,,1 u,l*
Appendicular Skeleton-Equine
-:
. . .. .. . .. 35
craprrn17 Interpretation Paradigms for the
A ppendi cul arS kel eton-E qui ne . . . . . . . . . 209
Clifford R. Berrv
.........42 N ancv E . Love
D onal dE . Thral l
crnprenl S TheS ti fl e . . . . . . . . . 215
Mary B . Mahaffey

, , ' .* ' ." ,

.i..jlil6b#i1€tlgp11lti;r,;,0..;|1]!l,lll..ir
cH ,cpren19TheTarsus . , . . . . . . 222
" "":. . ;jjt'lt,1i6,:3l1i;t"i.;,ll|! D ebraK . B ai rd
Axial Skeleton
csnpren
20 The Equine Carpus 227
cHAprER
6 InterpretationParadigmsfor the Axial Li sa N euw i rth
S k el e to n -Sma l l a n d L a rg eA n i mal ....... 57 J. Gregg B ori ng
NancvE. Love
cuprrn2l The Metacarpusand Metatarsus . . . . . . . . 247
CliffordR. Berrv
S tephenK . K nel l er
cHAprER
7 The Cranial and Nasal Cavities-
csnpren22The Metacarpophalangeal
Ca ni neandFeline . .......71
(Metatarsophal angeal
A)rti cul at ion . . . . . . 259
LisaJ. Forrest
R ussel lL. Tucker
cHAp rERS Eq ui ne Nas al Pas s ages andSinus es .. ...87 R onal dD . S ande
JimmyC. Lattimer
cH npreR 23
TheP hal anges... . . . . . . . . 269
cHAp rER9 The Ver t ebr ae- Canine and Feline . . . . . . . . 98 E l i zabethA . R i edesel
Michael
A. Walker
cttnprrn2ATheN avi cul arB one . . . . . . . 29s
csapren10 Canine and Feline Intervertebral Disc R obertL. Toal
Disease, Myelography, and Spinal
Go rd Dis eas e . . . . . ..... .. 110
WilliamR.W idm er llr|:€ffii.r$|$[\Y.tt,;,)1a,r;,g...arl;]vlre;|leerliil;:Xigr
Do na ldE.Thr ar r Neck and Thorax-Companion Animals
cHrprrn11 The Equine Vertebral Column . . . . 127 cuprrR25 Interpretation Paradigms for the
Russell
L.Tucker S mal l A ni mal Thorax . . . . . 307
R.Gavin.
Patrick ui l T IOr OH .6er r y
N anc v E. Lov e
D onal d E. T hr al l
,lllill{* ,' o' u'"' ' , F'.- .-;ll3:llOXoilll.o;.lo;le
|lfll:idi:l0ll9.;9::i,
cuprrn26 The Larynx,P harynx,and Trachea. . . . . . . 923
Appendicular Skeleton-Canine and Feline Stephen K. Knel l er
crapren
12 InterpretationParadigmsfor the crapreR 2TTheE sophagus.... . . . . . . . 329
AppendicularSkeleton-Canine B arbaraJean Watrous
and Fe l i n e . 135
Clifford R. Berrv crapreR 2STheThoraci cW al l . . . . . . . . 349
N a n c v E. L o ve C harl esR . R oot
D o n a ldE. T h r a ll R obertJ. B ahr

tx
X CO NT E NT S

cH A p rEB2gThe Diap hr agm . . . . . . . . . .. 3 5 9 craprrn41 The Liver and Spleen . . . . . 540

Richard
D. Park S usan M" N ew el l
John P .Graham
cHAPTER
30 The Mediastinum 376
DonaldE.Thrall craeren42The K i dneysand U reters . .. . . . . . 556
D ani elA . Feenev
cra p r r n3l T heP leu ra l S p a c e ...... ..390
Garv R . Johnston
D o n a l d E . T h r a ll

32 The Heart and Great Vessels

cHaprrn . - . . . 402 cH npren43TheU ri naryB l adder . . . . . . 571
R i chardD . P ark
C h a r l e sR . R o o t
Robert H. Wrigley
R o b e r tJ . Ba h r

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.

34 The Canine and FelineLung .

cHAprER . . . . . 431 cH npren45TheP rostateGl and. . . . . . . 592
C h r i s t o o h e rR. L a m b Ji mmy C . Latti mer

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

36 The Equine Lung

crapren 463 crapren48TheS mal l B ow el ...... . . . 639
C. S. Farrow Elizabeth
A. Riedesel

37 The Pleural Space

cHnprrn 475 c H A p r E R 4 gT h e L a r g e B o w e l . . . . . ....6 6 0
R u s s e l lL . Tu cke r DarrylN. Biery
R o n a l dD . Sa n d e

Abdomen-Companion Animals Radiographic Anatomy

38 Interpretation Paradigms for the

curprEn cHnpren
50 Radiographic Anatomy of the Dog
A bdom e n -C a n i n e a n d F e l i n e .... 483 and H orse ...... . . . 675
N a n c v E . L o ve James E . S mal l w ood
Clifford R. Berrv K athyA . S paul di ng

crn pr en39A bdom in a l M a s s e s .......493

C h a r l e sR . Ro o t ANSWERS . . . 727
cHa p r en40T heP er i to n e a l S p a c e .. ...516
Mary B. Mahaffey
D o n L . B a rb e r IN D E X .. . . . . . 743
 ' .,'
,.0,0,* t..'
PHYSICSAND PRINCIPLESOF
INTERPRETATION
CHA P T E R
1
Radiation Physics, Radiation
Protection, and Darkroom Theory
r Donald E. Thrall . William R. Widmer
X-rays were discovered on November B, 1895 by Wilhelm Conrad
Roentgen, a German physicist.r These new "rays" were quickly
put to use for medical purposes, and many sophisticated medical
applications were soon devised.For example, angiography was first
described in 1896, only i year after the discovery of x-rays. The
discovery of x-rays revolutionized the diagnosis and treatment of
diseasein man and animals. In 1901, Roentgenwas awardedthe
first Nobel Prize for Physicsin recognition of his discovery.
Over 100 years after their discovery,x-rays remain in widespread
use for many aspects of medical imaging. Although x-rays are
vaiuable for medical purposes, the interaction of x-rays with tissue
produces ionization, which may in turn produce significant bio-
logic damage. Becausex-rays are so widely applied yet potentially
harmful, it is important that their basic principlesbe understood.
I Basic properties of x-rays
X-rays and gamma rays are types of electromagneticradiation. The
distinction between x-rays and gamma rays is their source; x-rays
are produced by electron interactions outside the nucleus; gamma
rays are emitted from unstable nuclei. Other familiar types of
electromagnetic radiation include radio waves, radar, microwaves,
and visible light (Table 1-l).
Electromagnetic radiation is a combination of electric and mag-
netic fields that travel together. It is convenient to representelectro-
magnetic radiation as a "sine wave" model (Fig. 1-1). Sine waves
are characterizedby tuo related parameters, frequency and wave-
length. The velocity of electromagnetic radiation, which is the
speed of light, is the product of the frequency and the wavelength.
Velocity (m/sec) : frequency(cyclesper sec) X wavelength(m)
Table 1-1. Wavelength of common types
of electromagnetic radiation
Type of electromagnetic
radiation Wavelength (cm)
Radiowaves 30,000
Microwaves 10
Visiblelig ht 0 .0 001
X-rays 0.00000001
...' .
.l ' ..' .,_ lrW%#xffi
' _-.,.' ,' ,'
_ All tlpes of electromagneticradiation travel at the speedof light;
thrrs, frequency is inverselyproportional to wavelength.The energy
of electromagneticradiation is related to wavelengthby the formuli:
sPeed light
-h'nergy: Planck'sconstant -of
^ wavelength
Energy, therefore, is also inversely proportional to wavelength.
The basic energy unit for electromagnetic radiation is the elec-
tron volt (eV). An eV is the energy of an electron acceleratedby a
potential difference of 1 volt. Electromasnetic radiation with ener-
gies that are greater than 15 eV a .'erl low energy, can produce
ionization within living cells. Becausex-rays used for diagnosis
have energiesgreater than 1000 times this amount, the need to
understand their principles and to use them safely is clear.
Some physical properties of electromagneticradiation cannot be
explained adequatelyby theories ofwave propagation. The photon,
or quantum concept, was developedto explain the apparent partic-
ulate behavior of x-rays and gamma rays, and how they interact
with their targets to create an image or to causeradiation damage.
A photon is a discrete bundle of energy. properties of x-rays and
gamma rays are given in Thble 1-2.
It is the ionizing property of x-rays and gamma rays that renders
them hazardous. Ionization occurs when a photon ejects an elec-
tron from an atom, thereby creating an ion pair comprising the
negatively charged electron and the positively charged atom. After
ionization has occurred, the physical and functional characteristics
of the moiecule containing the ionized atom may be changed(Fig.
1-2). BecauseDNA is involved in al1metabolic and clonosenic cell
processes,an ionization may occur in the DNA, resultingiin "bio-
logic amplification."In other words, a lesion induced in one cell's
DNA can affect many cells for future generations.An ionization in
DNA can lead to an increased(1) rate of mutation, (2) rate of
abortion or fetal abnormalities, if irradiated in utero, (3) suscepti-
bility to diseaseand shortenedlife span, (4) risk of cancer,and (5)
risk of cataracts.2Such ionization interactions are exoloited in
radiation therapy with the intention of causing the deaih of can-
cer cells.
I Radiation protectionx
The object of diagnostic radiology is to obtain maximum diagnostic
information with minimum exposure of the patient, radiology
*Local, state, and national
regulations supersede any recommendations given in
this chapter.
2 PHY S I CS S IN T ER PR ET A TION
A ND PR IN C IPL EOF

Directionof Travel+

Figure 1-1, Sinewave modelof electromagnetic radiatlonThe distance

beiweencrestseparation, of
\, is the wave length.Anolhercharacterrstic
wavesls theirfrequencv,f, or thenumber per
of waves unittime Thevelocity
(ciof a waveis related
to wavelength andfrequencybytheformula,c: f x
\. Electromagneticradiatjon speed-thespeedof light.
traveisat a constant
Photon

personnel,and the generalpublic. The purpose of this section is

to indicate the protection required in various circumstancesand to
describeone or more methods by which the required protection Figure 1-2. The principle A photoninteracts
of ionization. with a K-shell
may be provided.Theserecommendationsdo not precludealterna- electronof an atom.Thestippled crrclerepresentsthe atomc nucleus. The
tive methods of achieving the radiation protection objectives. Be- electronis eiected;
therefore, theatomis ionized. onizationresultsin forma-
tionof an ionpair:
the negatively charged electronandthe positvey charged
causeblind adherenceto rules cannot substitute for the exerciseof atom.Subsequent to theionization,the photon,depending on itsenergy, may
sound judgment, theserecommendationsmay be modified in un- be completely absorbed,or it mayinteractwith otheratomsto produce more
usual circumstances on the professional advice of experts with ionization.
Theejected electron caninteractwith biologic
molecules, suchas
recognized competencein radiation protection. DNA,andproduce damage to macromolecules resulting
in celldeath.

Radiation units
For many years, the units roentgen, rad, and rem were used to
quantify radiation exposure, radiation absorption, and equivalent
dose, respectively.In 7977, the "International Systemof Units" (SI
units) was developed in keeping with the trend toward universal
adoption of the metric system.3The units roentgen, rad, and rem
are not coherent with the SI system. The corresponding SI units
for the roentgen and rad are coulomb per kilogram and joule per
kilo gram, respectiveiy.
Becauseionizing radiation has no mass and no charge, it can be
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-
ing the number of ionizations, that is, the electric charge,produced
rials varies considerably.Therefore, the radiation "dose" to ob-
jects with different absorption efficiencies will not be constant
when these objects are exposedto an identical quantity of radia-
tion (Fig. 1-3). The SI unit for absorbeddose is the gray (Gy).
The Gy is defined as the amount of radiation such that the
absorbed energy is 1 joule/kg of tissue. Before SI units were
accepted,the unit of absorbeddose was the rad, being equal to
100 ergs/g. By using appropriate conversionfactors, it can be
shown that 1 Gy : 100 rad. In soft tissue, exposureto 12.58
x 10-a C/kg (l roentgen) amounts to an absorbed dose of
100 x-rays 100 x-rays

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
absorberofx-rays than is soft tissue,exposureto bone of 12.58
x 10-a C/kg (1 roentgen) results in a bone-absorbeddose of
greater than 0.9 cGy. This differentiai between exposure and
absorption in soft tissue versus bone may be as great as a factor
of 4 to 5 with low-energy radiation. Differential x-ray absorption
between various tissues in the body is the basis of radiograph
production. As is discussedlater, the differential between expo-
sure "dose" and absorbeddose is inverselyproportional to pho-
ton energy.
Dose equivalenr-In living tissue, absorption of the same dose in
Gy from different types of radiation may not produce the same
biologic effect. For example, damage from particulate radiation,
such as alpha particlesand neutrons, is greateron a Gy-for-Gy
basis than damage from the same dose of x-rays. This is related
to differencesin "ionization density" for different types of radia-
tion. For example, a high-mass, heavily charged particle, such as
an alpha particle (a helium nucleus: two nuclear protons, two
nuclear neutrons, no orbital electrons)createsmany ionizations
that are very close to one another in the tissue in comparison
with a low-mass, lightly charged particle, such as an electron.
Electrons set in motion by x-rays interacting with tissue (ioniza-
tion) are the major source of damage resulting from x-ray
exposure; this is described in greater detail later. Therefore,
deposition of I Gy from alpha particle absorption does more
biologic damage than deposition of 1 Gy from x-ray absorption.
Damage from different types of radiation may be compared by
the use of a weighting factor, a numerical factor describing the
relative effectivenessof a particular type of radiation to photons.
The weighting factor for photons is 1.0; it is greater than 1.0 for
charged or particulate types of radiation such as neutrons or
alpha particles. In the SI system of units, the unit of dose
equivalencyis the Sievert (Sv); the Sv is derived from the product
of the absorbed dose in Gy and the weighting factor. Before SI
units were accepted,the unit of dose equivalency was the rem.
The rem was derived from the product of the absorbed dose in
rads and the weighting factor. Because I Gy : 100 rads, 1 Sv
: 100 rem. As a rule of thumb, an absorbed dose of I Gy from
photons results in an approximately equivalent dose of 1 Sv.
Radiation safety
The United States Nuclear Regulatory Commission (NRC) is the
official source for establishing guidelines for radiation protection.
The NRC has indicated that the annual occupational radiation dose
to individual adults should be limited to a maximum of 0.05 Sv (5
rem).n The NRC has not establishedan upper limit for cumulative
exposure.Previously,the NRC had recommended that one's cumu-
lative exposurebe less than [5 rem/yr x (n-18)], where "n" is the
age of the individual; this recommendation has been overruled in
favor of the ALARA principle (defined later in this paragraph).
Although the NRC is the official body regarding exposure limits
for ionizing radiation, other groups also make recommendations
regarding exposureto ionizing radiation. For example,the National
Council on RadiationProtection(NCRP), a governmentalscientific
group, meets regularly to review recent radiation research and
update radiation safety recommendations. According to the NCRP,
the objectivesof radiation protection are:
1. To prevent clinically significant radiation-induced effects by
adhering to dose limits that are below the apparent or practical
threshold,and
2. To limit the risk ofcancer and heritable effectsto a reasonable
level in relation to societal needs and values, and benefits gained.t
These objectives can be met through adherenceto the principle of
ALARA-that is, limiting exposure of radiation workers to a leve1
As Low As Reasonably Achievable-and by applying established
dose levels for controlling occupational and general public expo-
sure.6
Maximum permissible dose is the maximum amount of ab-
sorbed radiation that can be delivered to an individual as a whoie-
body dose or as a dose to a specificorgan and still be considered
safe.The term "safe" in this context means that there is no evidence
that individuals receiving the maximum dose mentioned will suffer
harmful immediate or long-term effects to the body as a whole or
to any individual structure or organ of the body. Although the
effect of very low doses of radiation is not known with certainty,
it is safestto assumethat any amount of radiation will have some
effect on the subject. Thus, one should keep in mind that whenever
an individual is exposedto ionizing radiation, some biologic dam-
age may occur, and following the ALARA principle is of paramount
importance. Analogy might be made to an individual smoking a
cigarette only once a month. There is no evidence with this fre-
quency of smoking that physical damage could result; however,
with increasing frequency of smoking, the probabiliry steadily esca-
lates by virtue of its cumulative effect. Unfortunately, there is no
establishedthreshold for either cigarette smoking or radiation un-
der which damage will not occur or over which damage will
definitelyresult.
In December1989,the National Academyof SciencesCommittee
on the Biological Effects of Ionizing Radiation (BEIR) produced its
latest report, which concluded that radiation risks had until then
been underestimated; specifically, it stated that the likelihood of
cancer induction after exposure to 1ow radiation doses is 3 to 4
times higher than was previously thought.T Many of their data were
derived from studies of survivors of the World War II atomic bomb
explosions in fapan. Very few large human exposuresto radiation
have been documented; however, events such as Hiroshima/Naga-
saki and Chernobyl have provided information on human totrerance
to low-level radiation exposure. Also, the Department of Energy
has recently released information derived from human radiation
exposure experiments that were conducted during the Cold War
period ofthe 1950sand 1960s.
Even though ALARA is the offrcial method of choice for limiting
one'sexposureto radiation dose,recommendationsfor upper limits
ofexposure have also been establishedby the NCRp to guide those
invoived in radiation work. The NCRP recommends the following8:
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
occupationalexposureshould be permitted until age 18. Therefore,
an individual's lifetime effective dose equivalent in rems should
not exceedthe valueof his or her agein years.
2. The effective dose in any 7 year should not exceed 50 mSv
(5 rem).
3. For the general public, radiation exposure (excluding that
relatedto medical use) should not exceed1 mSv (0.1 rem).
4. Once pregnancy is declared,the monthly limit of exposure to
the embryo or fetus should not exceed0.5 mSv (0.05 reml. Specific
controls for occupationally exposed women are no longer recom-
mended until a pregnancyis declared.
The difference in opinion between the NRC and the NCRp
regarding limits for cumulative exposure can be confusing. It is
important to recognizethat the NRC is the agencyoffrcially respon-
sible for identifying federal exposure standards. The NRC has
elected to eliminate any recommendations regarding cumulative
exposurelimits, probably becauseof the uncertainty of such predic-
tions. The NCRP, on the other hand, has elected to establish an
estimate for acceptablecumulative exposure, which is much more
conservative than that previously recommended by the NRC. Re-
gardless,it is in the best interest of the radiation worker to adhere
to the principle of ALARA regarding occupational exposure, and
to use the most conservative of any conflicting recommendations
as a guideline.
In addition to occupational exposure,the population is continu-
ally exposed to very low levels of radiation, both natural and
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"

Nuclearmedicine4%
Consumer
products3%
Radon55%
Other1%
/ ual from external radiation sourcesmay be achievedby any one or
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 by various sourceswas published by the NCRP in 1987
(Fig. l-a).'q Briefly, the averageU.S. citizen receives3.6 mSv (360
mrem) annually; of this figure, more than 800/ois due to inhalation
of radon gas. The relative levels of different sources of exposure
may vary based on geographic location. For example, owing to
greater altitude, exposureto cosmic radiation is higher in Colorado
than in North Carolina, and in Eastern Pennsylvania,household
radon exposure is much greater than in most other areas of the
United States.In Table l-3, tlpical radiation doses received from
some familiar activities are shown.
Biologic principles
X-rays produce electron pairs (ionization) in tissue.Becausemost
tissue is 70o/owater, ionization of water moleculescausesthe forma-
tion of chemically active free radicals. These free radicals account
for most of the damage to tissue. A small percentageof x-rays
interact directly with DNA, resulting in severalpotential alterations
such as base nucleotide damage, DNA strand breakage,and DNA
cross-linkage.These effects may be minimal and quickly repaired
enzymatically, or can result in lethal damage to the cell. DNA is
uniquely sensitiveas it is a large target relative to other intracellular
structures and possesses little redundancy within any one cell. The
principle of biologic amplification as described previously is an-
other reason why DNA damage can have serious consequences.
Depending on the tissue involved, a given dose of x-rays can
have effectsvarying in magnitude from imperceptible to lethal. The
type of tissue irradiated has an impact on the effects of radiation.
For example,a tissue that does not divide, such as muscle, may
receivea high dose but exhibit few side effects.Conversely,actively
dividing tissues, such as intestinal epithelium and bone marrow
are quite responsiveto radiation.
Two other tissues, gonadal and fetal, are of crucial importance
with respect to radiation safety. Irradiation of these tissues at
sensitive stagescan result in biologic amplification of any damage
Tahle 1-3. Radiation doses received from some
familiar activities*
Radiation dose
Event received (mSv)
FIightfrom Los Angelesto Paris
T hora cicrad iog rap h
Apollo X astronauts'moon flight
Whole-mouthdental x-ray
Dose o n Thre e Mile ls landdur ino ac c ident
Mam mog rap hy
B ariumen ema
Heartcatheterization 450.0
Radia tionth era py 70,000.0
*Doses are whole bodv in some instances and reoional in others.
Practical considerations
Radiation workers in veterinary practices must be aware of the
risks of radiation. They should be skilled in proper patient posi-
tioning for radiography, machine operation, and darkroom tech-
niques so that repeat radiographic studies are minimized. Workers
should be instructed on the proper use and care of radiation
protection devices.Reduction of radiation exposure to an individ-
any combination of the following measures:
radiation source
2. Time-reducing the duration of exposure
3. Shielding-use of protective barriers between the individual
and the radiation source
In veterinary medicine, shielding and distance are the factors
most readily controlled.Shieldingmay comprisepermanentprotec-
tive barriers and structural shielding such as wa1lscontaining lead,
concrete, or other materials in thickness sufficient to provide the
required degree of attenuation. Shielding may also be a protective
barrier incorporated into equipment, such as an aluminum filter
to remove scattered radiation or a collimator to limit the size of
the primary x-ray beam. Or, shielding may consist of mobile or
temporary devices used as the occasion demands, such as movable
screensor lead-impregnatedaprons or gloves.
Protective aprons and gloves are usually 0.5 mm Pb equivalent,
and they must be worn when one is positioning patients for
radiography. Although these devices are heary and seemingly pro-
vide considerableprotection, they are designedsolely for protecting
against scatteredradiation and must never be placed in the primary
beam. In addition, mishandling of this equipment will result in
its cracking, and therefore affording less protection. Protective
equipment should be treated with respect;it is used to protect the
health of the radiation worker.
Pregnant and potentially pregnant women, and individuals
younger than 18 years of age, should not hold animal patients
during radiologic examination or treatment. A radiation protection
supervisor (who may also be the user) should be designatedfor
every installation to assumethe responsibilities outlined later and
to advise about the establishment of safe workine conditions in
compliance with all pertinent federal, state, and lola1 regulations.
Radiation protection supervisors should be familiar with the basic
principles of radiation protection to properly carry out their re-
sponsibilities, although they may wish to consult with appropriate
qualified experts for advice.
Suggestedresponsibilities of the radiation protection supervisor
are the following:
1. To establish and supervise the implementation of written
operating procedures and to review them periodically to ensure
their conformity with local regulations
2. To instruct personnelin proper radiation protection practices
3. To conduct or have conducted radiation surveys where indi-
cated and to keep records of such surveys and tests, including
summaries of corrective measuresrecommended or instituted
NF 4. To observe routinely and test periodically interlock switches
.22 and warning signals to ensure that they are working properly
4.8 5. To ensure that warning signs and signals are properly located
9.1 6. To determine the cause of each known or suspectedcase
11.0
of excessiveabnormal exposure and to take steps to prevent its
| 5.U
80.0 Iecurlence
Personnel monitoring
Personnelmonitoring is used to (1) check the adequacyof the
radiation safety program, (2) discloseimproper radiation protec-

- G-l
 RadiationPhysics,RadiationProtection,and DarkroomTheory 5
tion practices, and (3) detect potentially serious radiation exposure
situations. A radiation badge is a common personnel monitoring
device. A radiation film badge consists.of a plastic holder that
contains a paper-wrapped piece of photographic film. When struck
by ionizing radiation, the film becomesexposed,and the degree of
film blackness can be related to exposure. Radiation badges may
contain thermoluminescent dosimeters rather than film. These do-
simeters trap electrons energized by oncoming radiation, and the
number of trapped electrons can be quantified and related to
exposure. Radiation badges should be analyzed at least quarterly;
weekly inspection is preferable.
Personnel monitoring should be performed in controlled areas
for each occupationally exposed individual for whom there is a
reasonablepossibility of receiving a dose exceedingone fourth the
applicable maximum permissible dose. A qualified expert should
be consulted on establishment and evaluation of the personnel
monitoring system. Devices worn for the monitoring of occupa-
tional exposure should not be worn by the individual when he or
she is exposed as a patient for medical or dental examinations.
Monitoring devices should be worn on the chest or abdomen,
except for special circumstances.\A/hen a protective apron is worn,
the monitoring device should be worn on the outside of the apron
for monitoring the radiation environment, but may be worn inside
the apron when an estimate of the body exposure is desired.
Basic radiation safety rules for diagnostic
radiology
1 Remove personnel from the room who are not involved in
the procedure.
2. Never permit anyone younger than 18 years of age, or
pregnant women, in the room during the examination.
3. Rotate personnel who assistwith radiographic examinations
to minimize exposure to any one person.
4. Use sandbags, sponges, tapes, or other restraining devices
for positioning the patient rather than manual restraint.
5. Use anesthesiaor tranquilization for patient restraint when
possible.
6. Never permit any part of the body to be in the primary
beam, whether protected by gloves or aprons or not.
7. Never handhold an x-ray tube, x-ray machine, or cassette.
B. Always wear protective aprons when assistingin positioning
an anlmar.
9. Always wear protective gloves if hands are placed near the
primary beam.
10. Consider use of protective goggles if work level is hearry.
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-
quent interaction with a metal target. Electric current is passed
through the filament of the x-ray tube, in much the same way that
an electric current is used to heat the filament of a light bulb. The
heat allows electronsto "boil" off of the surfaceof the filament into
an electron cloud around the filament. The number of electrons in
the cloud is directly related to the amount of electric current
passingthrough the filament, which in turn is regulated by the mA
(milliamperage) control on the panel of the x-ray machine. Increas-
ing miliiamperage is analogous to increasing the wattage of a light
bulb. A 100-watt bulb has a hotter filament and emits more light
rays per unit time than does a 60-watt bulb. There is more current
flowing through the filament of a 100-watt bulb than through a
60-watt bulb.
X-rays are produced at the anode (target). Electrons that have
been produced at the filament remain stationary; thus a mechanism
by which they can strike the metallic target is needed. This is
accomplishedby applying a voltage differential between the anode
and cathode. Electrons are negatively ( - ) charged. Therefore, if
the target is positive ( + ) with respect to the filament of the
cathode, the electrons will be attracted to the target (opposite
charges attract) and strike it. The energy of x-rays produced is a
function of the energy of the electronsstriking the anode. Electrons
traveling through a larger potential voltage difference will have
higher energy.The potential voltage difference is adjusted with the
kilovoltage peak (kvp) control on the x-ray panel. Increasing kVp
increasesthe voltage difference between the anode and cathode;
thus, electrons are acceleratedto higher velocities and have greater
energy when striking the anode. This enables the production of
high-energyx-rays (Fig. 1-5).
When electronsstrike the metallic target, x-rays are produced by
either collisional or radiative interactions.l0Collisional interactions
involve a collision between a high-speed electron and an atom in
the target of the tube. The oncoming electron ejects an orbital
electron from the atom with subsequentreleaseof energy as an x-
ray (Fig. 1-6). X-rays produced by this mechanism have specific
energiesrelating to the energy required to eject the target electron
from its shell (the binding energy) and are therefore called charac-
teristic x-rays. X-rays createdby collisional interactions account for
only a small fraction of the total x-raysproduced in a diagnostic x-
ray tube.
In a radiative interaction (Fig. 1-7), the oncoming high-speed
electron passesclose to the nucleus of the target atom (attracted
by the opposite charge) but an electron is no1 ejected from the
atom. As the oncoming electron slows as it bends around the
nucleus, it releasesenergy in the form ofelectromagnetic radiation,
called "braking radiation," or bremsstrahlung. The energy released
in the form of bremsstrahlung has a broad spectrum, depending
on the amount of energy lost from oncoming electrons as they are
deflected to various degreesby the nucleus. Most electrons have
pe
Cathode
Figure l-5. A schematicdrawingof a rotating-anode x-raytube. The anode
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

2. The outershellelectronof a Photonenergy(kev)

+I
higherenergylevelfillsthevoidin
theinnershell;thedifferencein
I
kVp
energl.,levels is emitled as an
x-rayphoton. 3. X-rays originatingfrom Figure 1-8. Thespectrum of x+ayenergythat Lsproduced by braking and
this processcan be used characteristic
radiation.
Themaximum energy x-rayphoton
achievable is equal
for imaging.
to the kiovoltoeak(kvp).Forthisto occur,anelectronmustbe acceleratedat
Figure 1-6. Thecollision modelof x+ayproduction. An electronproduced maximal velocity As illustrated,
andlooseallof its energyln oneinteraction.
in anx-raytubeis acceleratedto high-speed through a potentialdifference and the numberof x+aysin the spectrum with an energyequalto the kvp is
anatomjnthetargetof thex+aytube.ln somecollisions,
strikes theoncoming verysmalt.
electronwilleiectanorbital electron fromthetargetatomandcontinue on at
a differentangle.Atomswith vacancies in electron shellsareunstable, and
thevacancy filledby a moreperipheral
is quickly electron, or a freeelectron
Whenthisoccurs, energy thatwas deposited by the originaloncoming elec- It is very important that the difference between kVp and keV*
tron,whichresuited in ejectionof thetargetelectron, is released in theform is understood. The kVp (kilovoltage peak) refers to the maximum
of electromagneticradiation,calleda characteristicx+ay.In general, electrons
energy than voltage applied to the x-ray tube acrossthe anode-cathode gap. In
nearthe nucleus
in shelJs aretightlyboundandhavelesskinetic
thosein peripheral
shells. Electronsinthemostperipheral shellsareessentially the United States,electric current is alternating; thus for any given
"free"andhavemoreenergyowingto theirweakattraction to the positively kVp setting, the voltage potential difference across the anode-
charged nucleus.Therefore, asanelectron is ejectedfromthe K shell,replace- cathode gap fluctuates between positive 110 volts and negative 110
mentelectrons mustgiveup energybeforetheycanoccupythe K shell volts (Fig. 1-9). The term keV (kiloelectron volt) is a unit of
energy to describe the energy of either electrons or photons. If the
many interactions with atoms of the target as their kinetic energy kVp is set at 100 (100,000volts maximum differential between the
is dissipated. anode and cathode), electrons traveling from anode to cathode
There is a range (spectrum) of energies of x-rays produced for have energiesequal to or less than 100 keV (100,000 electron
any given combination of mA and kVp settings. This results be- volts). Few electrons achieve an energy of 100 keV becauseof the
cause (1) most electrons undergo multiple radiative interactions fluctuating nature ofthe voltage acrossthe anode-cathodegap; that
resuiting in production of x-rays with different energy' and (2) is, the voltage is at its maximum value for only an instant during
there is a wide range of energieswithin the electrons striking the each cycle. If a 100-keV electron loses all of its energy in one
anode (Fig. 1-8). The maximum x-ray photon energy achievableis interaction, it produces an x-ray photon with an energy of 100
one with an energy equal to the kVp. For this to occur, an electron keV. But this is very uncommon. Only a few x-ray photons in the
must be acceleratedat maximal velocity (a function of kVp) and beam will have an energy that is equal to the kVp, and it is unusual
lose all of its energy in one interaction. The number of x-ray for an electron to lose all of its energy in one interaction (see
photons in the spectrum with an energy equal to the kVp is very Fig. l-B).
small (seeFig. 1-8). Here a basic discussion of problems relating to the use of
alternating current for production of x-rays is necessary.If alternat-
ing current (see Fig. 1-9) were to be used for x-ray production,
3. This eiectron may
produce additional x-ray there would be times in the current fluctuation cycle that the
o- photons through additional cathode would be positive in relation to the anode. Any free
collisional or radiative
interactions. electrons at the surface of the anode, present becauseof the high
temperature of the anode, would be attracted to the cathode and
'1. The oncomingelectron
damage it. To avoid this, alternating current is converted to direct
fromthe cathodeof an current using a processcalledrectification.An in-depth discussion
x-ray tube "brakes"and of rectification is beyond .the scope of this book. What must
bendsaroundthe
nucleusbecauseof the be understood here is that rectification results in direct current
difference in charges. O: application across the cathode-anode gap, and electrons therefore
2. As the electron slows, only travel from the cathode to the anode.
energy is released as
an x-ray, which may Much of the energy (>90o/o)of the electronsstriking the anode
be used to make an
image.
is converted to heat. Therefore, x-ray tube targets are tlpically
made of high-melting-point substances,such as tungsten. Addi-
tionally, as an ancillary heat dissipation mechanism, the anode may
rotate to increasethe effective surface area struck by the oncoming
Figure 1-7. The radiative,or braklng,modelof x-rayproduction.An electron high-speed electrons.Anode rotation prevents the target from melt-
that is oroducedin an x-ravtube is acceleratedto high-speedthrougha large ing or becoming "pitted;' as would happen if electrons continually
potentialdifference.Becauseof the differencein chargebetweenthe electron struck the same target region. Thrgets in x-ray tubes are also
(negative)and the nucleus(positive),the electronis deflectedas it nearsthe
nuc le u s .A s t h e d e f l e c t e de le ctr o nd e ce le r a te s, it r e le a se se le ctromagneti c
*An electron volt (eV) is the amount of energy an electron gains as it is accelerated
radiationin the form of an x+ay. Becausedeflectedelectronsmay passwithin
h a sa sp e ctr u mof energi es
v ario u sd i s t a n c e so f t h e n u cle u s,b r a kin gr a d ia tio n by a potential difference of 1 volt. I keV : 1000 eV

c
 RadiationPhysics,RadiationProtection,and DarkroomTheorv 7
1/60sec
-
+
+ spot w hi l e mai ntai ni ng
+ of mAs is analogous to leaving a 60-watt bulb burning twice as
Figure 1-9. Theconceptof rectification. ln the upperpanelthe fluctuation
thatis typical
of alternatingcurrentis illustrated.
Thereis onecomplete cyce
each60 sec.lf thiscurrent wereusedfor voltage appicationin thex-raytube,
thecathode (filament)woud be positive in relationto theanode(target) 50%
of the time.Whenthe cathode is positive, anyfreeelectrons at the anode
created by heatbuild-up woud travelto thecathode anddamage it.Themiddle
paneilllustrates the patternobtainedwhen currentis not allowedto flow
duringthenegative phase of thecycle.Inthisinstance, electronswillnotflow
from the anodeto the cathode. One disadvantage of this typeof current
modificationis a lossof potentially
usefulcurrent during thenegative phase of
the cycle.Methods havebeendeveloped to reverse the direction of current
flow in halfof the cycle.The resutant waveform is shownin the bottom
panel.This is calledfull-waverectificationand resultsin one usefu pulseof
currentevery1/zosec.
typically made of a high-atomic-number material, such as tung-
sten, because the efficiency of x-ray production from electron
interactions is directly related to atomic number.
The focal spot is the region of the target struck by electronsand
thus is the site of x-ray production. The smaller the focal spot, the
better the detail on the radiograph. A practical example of this
phenomenon is the sharpnessof a shadow cast by a large versus a
small light source.A shadow cast by a small light source, assuming
the distance from the light to the object is constant, will alwaysbe
sharper than a shadow cast by a large light source (seelater section
on detail). Therefore, it is desirable to have the smallest focal spot
possible. Angling the anode is one way to make the focal spot of
the x-ray tube appear smaller than it really is, while at the same
time maintaining a larger area on the anode being struck by
electronsto facilitateheat distribution (Fig. 1-10).
Some x-ray tubes have two focal spots (fr1aments),which are
operator selectable.The small filament is used to produce a small
focal spot when greater image detail is necessary.One disadvantage
of using the small filament is that one must also use low mA values
to prevent the filament from burning out.
As has aiready been stated, increasing milliamperage increases
the number of x-rays. The number of x-rays produced can also be
controlled by altering the length of time the x-ray tube is energized.
The timer on the x-ray machine panel controls the length of time
current is applied to the cathode and voltage is applied acrossthe
anode-cathodegap. X-rays are produced only when there is both a
Apparenl
focal spot
stze
Figure 1-1O. Anglingthe anode decreasesthe stze of the effectivefocal
a l argerareaon the anodethat i s struc kby el ec trons
and thus faci l i tates
heatdi stri buti on.
source of electrons and a voltage differential across the anode-
cathodegap.
The concept of milliampere seconds (mAs) is used to quantify
the amount of radiation produced by the x-ray tube. The concept
long as a 120-watt bulb; in both instances,the total number of
light rays emitted would be the same, although the intensity at any
one time would be twice as great for the 120-watt bulb. mAs is the
product of mA (the setting on the control panel) and time, in
seconds.A variety of combinations of mA and time can be used
to produce the same number of x-rays (Table 1-4).
X-ray generators provide electrical energy to the x-ray tube to
produce x-rays.ll'12Components within the generator allow the
operator to select kVp, mA, and exposure time. X-ray generators
also protect the x-ray tube from being damaged by excessiveexpo-
sure factors. The main components of an x-ray generator are the
high-voltage circuit (which regulates voltage potential across the
anode-cathodegap, e.g., kVp), the filament circuit (which regulates
filament current in the x-ray tube, e.g., mAs), and circuits for
automatic exposure control.
X-ray generation requires potential differencesof 40,000 to
120,000volts (40-120 kVp) in the x-ray tube. Thus, transformers
are needed to boost by 500- to 1000-fold the relatively weak input
voltage from a standardpower source (110-120 volts). Operation
of a transformer is a complex process, and only a simplified
explanation follows. Transformers transform a given input voltage
to a new output voltage. A moving charge such as an electric
current produces a magnetic field. The magnetic field oscillatesin
conjunction with the sinusoidal change in polarity of a 60-Hz
electric current (Fig. 1-11). Conversely,a moving (oscillating)
magnetic field generatesa flow of electrons (current) in a wire that
is capable of conducting electricity. The transformer exploits this
phenomenon by using the magnetic field of input current of a
primary circuit to induce a current in an adjacent, secondary
circuit. The primary and secondarycircuits are arranged in parallel
opposing coils or windings and are insulated, so there is no contact
between them (Fig. 1-12). If the number of windings of each
circuit is equal, the transformer will generate identical output
current and voltage in the secondary circuit. However, if the sec-
ondary circuit has more windings than the primary circuit, the
Table 14. Constant mAs can be produced by a variety
of mA and time combinations
'l'ime (sec)
mA mAs
50 0.1
100 0.05
500 0.01
1000 0.005 5
8 P HY S I CS O F IN T ER PR ET A TION
A ND P R IN C IP L ES
Figure 1-11. Theconcept of electromagnetic Thereareoscillating
radiation
planes.Herethe E
/E/andmagnetic
etectric 1Hlfieldsmovingin orthogonal
andtheHfieldmovesin theZdirection
fieldmovesin the tdirection llme is
tntheX direction.
induced current will have a higher voltage. This is because the
magnetic field or flux generatedby the primary windings interacts
with a greater number of secondary windings. The ratio of the
number of secondary and primary windings is proportional to the
output voltage. Thus, if there are twice as many secondary as
primary windings, the output voltage will be twice the input
voltage. Such a transformer is called a step-up transformer'In x-ray
gett".utotr, the incoming (line) voltage of the primary circlit of
ihe step-up transformer can be adjusted using the kVp selector.
This reiults in selectableoutput voltage from the secondary circuit
that is applied to the x-ray tube. This tlpe of transformer is called
an autotransformer.
The generator also houses a low-energy circuit that supplies
current 1o the filament of the x-ray tube. Only a weak current is
needed to heat the tungsten filament of the cathode' and even a
standard 110-volt, 5A, 60-Hz current is too strong. Therefore, a
step-downtransformer is used to reduce the incoming voltage to 10
,roits. Th. step-down transformer has adjustable primary windings,
allowing it to function as the mA selector. Overall, the step-down
transformer has fewer secondary than primary windings. The mA
selectorcontrols the current passingthrough the filament, and thus
the number of electrons available for acceleration to the cathode
where x-ravs are produced.
lron core
Primary Secondary
windings windings
Figure 1-12. Diagramof a step-uptransformer'The magnetic{ield in the
primary winding inducesa current in tfr- secondarywinding Becausethere
y d in g s,th e vo lta g ewiJlb e in cr eased-here
are m o r et u r n si n t h e s e c on d a rwin
by a factor of 5/4 as there are 5 turns on the secondaryside and 4 on the
piimaryside. Energymust be conserved,thus there will be a proportionaldrop
in amperage(by a factor of 4/5) on the output side
,4'. \./\.,' ,4..
1/60 sec
' Single-phaserectified
1/60 sec
Three-phasefully rectified
Figure 1-13, lllustrationof the ripplefactor.ln single-phase, x-
unrectified
ray machines, voltagefluctuates from zeroto +110Vto zeroin 1/1zo sec,
followed by no voltagefluctuationfor %20sec,thenfromzeroto +110Vto
zero in the nexl 1/zo,and so forth. By introduclng three separate current
sources (waves),eachoutof phasebythe samedegree, the rlpplefrompeak-
to-peak Useof threeseparate
is diminished. current sources is calledthree-
phasetechnologlz by the darkhneconnecting
The rlpplefactoris iLlustrated
by the three-
the topsof the currentcycles. Thisclearly hasbeenreduced
phasemethod.
There are several t1ryesof generators,l'zbut only three are dis-
cussedhere: single- and three-phasegenerators,storagegenerators,
and high-frequency generators.Single-phasegeneratorsare con-
nectedto a single-phasealternatingcurrent input line (Fig. 1-13).
Single-phasegeneratorsare problematic becausethe polarity of the
alternating current reversesevery 1/60 of a second. Therefore, only
half of each cycle is useful for acceleratingelectrons acrossthe tube
(seethe previous discussionon rectification).It is easyto seethat
even with full-wave rectification, the large fluctuation between
maximum and minimum voltage, or ripple factor, during an expo-
sure (evident in Fig. l-13) is undesirable. However, with a three-
phase alternating current, the ripple factor is significantly reduced
because the alternating current arrives in three separate phases
with respect to time. Three identical lines supply the transformer
of a three-phasegenerator,allowing the waveforms of all to be 120
degreesout ofphase with eachother (seeFig. 1-13). This obviously
provides lessfluctuation between maximum and minimum voltage,
giving a smaller ripple factor. Although a small ripple factor is
desirable, attainment of it adds to the complexity of an x-ray
machine and increasescost. Advantages of three-phase generators
include shorter exposure times and higher kVp. Most large, stand-
ing x-ray machinesuse three-phasegenerators,and portable units
have single-phasegenerators.
High-frequency generatorsare the current state-of-the-art power
source for x-ray tubes. These generators produce extremely high-
frequency, high-voltage output that has a near-zero ripple factor.
First, incoming three-phase alternating line current is converted
into direct current. Next, the current is chopped into a high-
frequency square wave current and fed to the primary windings of
a step-up transformer. The frequency of the tube current is 500 to
4000 Hz, which produces a low ripple factor. The generator also
contains capacitors in the high-voltage circuit that help "hold"
constant potential acrossthe x-ray tube. With additional smooth-
ing, the final waveform acrossthe tube is almost a flat line, or of
constant potential. High-frequency generators are also compact,
relatively inexpensive, and easily maintained. Therefore, they are
the most desired type of x-ray generator and are commonly used
in x-ray machines that are manufactured for veterinary practices.
I Interaction of radiation with
I matter
To understand how radiographs are produced using x-rays, it is
necessaryto understand how radiation interacts with matter. There
are five possible mechanisms of interaction of a photon with
 RadiationPhysics,RadiationProtection,and DarkroomTheorv 9

the photon energy(probability proportional to UE.). The relation-

ship between the photoelectric process and the atomic number of
3. W hen the s hel l
vacancy is filled, the absorber (the patient) is very important. This relationship
characteristicradialion "magnifies" differencesin absorption ability of various tissue types
is given off. This such as bone versus soft tissue and soft tissue versus fat. If it were
1. T h e i n co mi n gp h o ton radiation is of very low
lrom an x-ray tube ejects energy. not for the atomic number dependenceof the photoelectric effect,
the orbital electron there would be insufficient differential absorption ofx-ray photons
f rom the tissue atom, between tissues for the resultant image to have any contrast, that
completely absorbing the
photon's energy.
is, all tissues would appear of similar opacity on the radiograph
and the radiograph would be useless.Arother advantage of the
photoelectric effect is the lack of exposure of the x-ray film due to
scatteredphotons (film fog, see later section), which decreasesthe
exposure to adjacent personnel. However, patient dose associated
with the photoelectric effect is high because all of the energy of
2. The shell vacancy is
.}- the incoming photon is absorbed in the patient. Obviously, the
filled by the more (The ejected orbital photoelectric interaction is good for the radiograph but bad for
^a r i n h a r , l ^r
{r a o electron- the the patient. The decreasein probability of photoelectric absorption
eteclron. photoelectron- is
capable of producing
as the energy of the photon beam increasesresults in a loss of
more tissue contrast between tissues of various tlpes when very high-energy
ion ization) photons are used for radiography.
Figure 1-14. The photoelectriceffect. An incomingphotonfrom the x-ray Compton scattering. Almost all scattered radiation that is
t u b e e j e c t s a n e l e c tr o n ,u su aly fr o m a n in n e r sh e ll o f a tissue atom. The encountered in diagnostic radiology results from Compton scatter-
in c o m i n gp h o t o n s c om p le te ya b so r b e dEle . ctr o n in s sh e ls nearthe nucl eus ing. In the Compton reaction, an incoming x-ray photon interacts
a r e t i g h t l yb o u n da n d h a vele ss kln e tice n e r g yth a n th o se in peri pheral shel l s. with a peripheral shell electron of the patient. The electron is
E l e c t r o n si n t h e m o st p e r p h e r a lsh e llsa r e e sse n tia liy"f r e e ," ow i ng to thei r
w e a k a t t r a c t i o nt o t h e p o sitive lych a r g e dn u cle u s.T h e r e fo r e,as a photoel ec- ejected, and the photon is scattered at a different angle; the scat-
t r o n i s e j e c t e df r o m th e K sh e ll,r e pa ce m e n te le ctr o n sm u st gi ve up energy tered photon has lower energy than the original photon (Fig.
ra6\/ ^r, +na shol
^6r^16 Thq cnprnrr is rataAcad n the fO.m Of a 1-15). The scatteredelectron is called either a Compton electron
photon,calledcharacteristic
radiation shel energyievelsarespecific
because or a recoil electron. The probability of a Compton reaction depends
to thetypeof atom.In tissue, radiation
thecharacteristic is of extremely
low
energy andis absorbed. on the total number of electrons in the absorber (patient), which
in turn depends on its physical density (g/cm.) and number of
electrons per gram. The probability of a Compton interaction
matter. They include (1) coherent scattering, (2) photoelectric increasesas photon energy increases.Becausemost elementscon-
effect,(3) Compton scattering,(4) pair production, and (5) photo- tain about the same number of electrons per unit mass, the proba-
disintegration. Pair production and photodisintegrationhave no bility of a Compton reaction is independent of atomic number.
relevanceto diagnostic radiology and will not be discussed.A basic Such independence is disadvantageous.This pertains to the third-
descriptionof the coherent,photoelectric,and Compton processes order (proportional to Z3) dependenceof photoelectricabsorption
is given; sourcesfor more detaiied reading are available.") on atomic number, which results in great differencesin absorption
Coherent scattering. A photon interacts with an object and (good tissue contrast) between tissues,versus the first-order depen-
changesits direction, but there is neither absorption of the photon dence (proportional to Z) of Compton absorption on physical
by the subject nor a change in photon energy. The percentage of density differencesor electron density differencesbetween tissues,
x-rays striking a patient that undergo coherent scattering is small, which results in very poor contrast. Thus, if the energy of the x-
approximately 57o. Coherent scattering is not useful in the produc- ray beam is such that Compton absorption predominates, there
tion of the radiograph and is in fact disadvantageousbecausethese will be very little contrast in the image. This is why it is important
scattered photons may strike the x-ray film and degrade image in radiography to use x-ray beams that have an energy in which
quality (see later section), or they may strike the radiographer,
thereby increasing his or her 1evelof exposure.
Photoelectric effect. The photoelectric effect is very important
in diagnostic radiology. The x-ray striking the patient is totally 2. The scattered photon,
called a Compton photon,
absorbed(Fig. 1-l ), and, therefore,there is no scatteredradiation has lower energy than the
to contend with. The absorbed x-ray photon ejects an electron, incoming photon, but may
produce more ionizations,
called a photoelectron,from an inner shell of a tissue atom. The - of may fog the film and is a
1. The incomingphoton
photoelectron may produce multiple ionization events in the tissue tromthe x-raytubeejectsan
radiation safety hazard.

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
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 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
absorbed in the patient and make no useful contribution to cre-
ation of the image. Therefore, filters are routinely placed in the
x-ray tube housing to remove these low-energy x-rays' Some
x-rays passingthrough the filter are absorbed by the beam-shaping
coliimator or tube housing and do not hit the patient. The collima-
tor servesto limit the primary beam and prevent nonuseful radia-
tion from leaving the tube housing. This nonuseful radiation oniy
serves to (1) increase patient dose, (2) degrade image quality
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-
tient and will be recordedon the x-ray film' Some fraction of the
x-ravs must penetrate the patient or no information would be
,..oid.d on tire fllm. The middle x-ray hits a structure within the
patient and is completely absorbed. This is also beneficial and
emphasizesan important point: radiographsare possibleonly be-
cause of differential absorption of x-rays by the patient. The x-ray
on the right hits the patient and is scatteredin another direction.
In this initance, the x-ray will strike a bystander. If the bystander
is not wearing a protective apron and gloves,he or she will receive
an unnecessary radiation dose. If the angle of scatter had been
different, the scattered x-ray may have hit the x-ray film' This
would be disadvantageousbecausethe x-ray no longer represents
a structure within the patient. This x-ray would "fog" the film.
A radiograph is a visible image of the internal make-up of an
object, usually a patient. The radiograph is used to assessinternal
structures. There must be some method of recording an image of
an obiect if it is to be critically assessed.Fortunately, one of
Tube
housi ng
Filter
Collimator
Edge of collimated
x-ray beam
Patient +
X-ray film
Figure 1-16, The schematicrelationshipbetween x-raytube patient,and
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 .
50 mAs 100 mAs 200 mAs
t
I i
I I
ll{):':'lti}')::'lla.'
iil!uu..
l.,rlill,,,illl;lll.9l
?1,,,,,r1
Figure 1-17. Thenumberof x+aysreachlng the fllm,andthereforefilm
blackness,
canbecontrolled bychanging themAssetting panel.
onthecontrol
Increasing
milliampere seconds {mAs),whilekeeprng peak(kVp)
the kilovoit
constant, strikngthepatentand,thus,proportionally
willresultin morex-rays
willpassrhrough
'no'ex-rays tnepat,enr t. -hus as rAs s ncreased,
o' oojec
filmblacknesswillalsoincrease.
the important characteristics of x-rays is their ability to expose
photographic emulsions.Therefore,x-rays passingthrough an ob-
ject, or patient, can exposephotographic emuision in such a man-
ner as to present a picture, or image, of the interior of the body.
There are some important aspectsof this processthat must be
understood now, although the radiographic image itself is dealt
with in greater detail in Chapter 5.
Film blackness/opacity
X-ray film is basically photographic film with a light-sensitive
emulsion. Silver halide crystals are present in the emulsion and
when exposed to x-rays or 1ight, they become precipitated on the
film during development as neutral silver deposits. These neutral
silver deposits appear black to the eye; unexposed crystals are
removed during fixation, leaving clear areas on the fi1m. Thus, it
is the amount of precipitated silver in any particular part of the
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).
When more x-rays are emitted, more reach the film (Fig. 1-17).
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
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
(FFD). As the FFD increases,film blacknessdecreases becausethe
intensity of x-rays in the x-ray beam (x-raysiunit area) decreases
(Fig. 1-1e).
The amount of change in intensity of the x-ray beam as a
function of distanceis describedby the inversesquarelaw equation:
(d,)'
-
(d,)'
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).
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
will the intensity be if the FFD is decreasedto 25 inches?Intuitively,
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

100 x-rays 100x-rays 100 x-rays

50 kvp 70 kvp 90 kVp

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

Figure 1-19. As distance from the x-ray source {anode)increases,the
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
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
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,
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.
: 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
values, which preserveradiographic detail (see later discussion),
and short values, which require lower mAs values. Use of a long
FFD to preservedetail cannot be recommendedbecausethe large
mAs values needed to maintain x-rav intensitv at the film are
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
longer exposure times are needed, which may result in patient
motion, a cause of image unsharpness.FFD values are typically in
the range of 40 to 60 inches.
I Factors affecting image detail
Motion
Motion is the biggest enemy of detail in veterinary radiology.
Animals cannot be kept completely motionless unless they are
anesthetized,and any motion will induce image unsharpness.To
avoid image unsharpness due to motion, it is desirable to use a
fast exposure time. In some x-ray machines, the timer is capable
of limiting exposures to the millisecond range. When exposure
times become very short, the mAs must be very large; otherwise,
the mAs will be too low to produce the necessary1evel of film
blackness.Milliampere valuesup to 1500can be obtained in some
x-ray machines. In private practice, however, choice of mA values
is more limited and most machines have maximum mA values of
300. This means exposure times must be longer to obtain suitable
mAs values,and motion becomesmore of a problem. Motion can
be combatedby (l) not using a long FFD (requiresmore mAs and,
therefore, longer exposure time); (2) not using detail film; (3)
using high-speedscreens(rare-earth);and (4) using a grid with a
medium grid ratio (e.g., 8:1). All of these factors are included in
the subsequentdiscussion.
Film speed
X-ray film is available in a variety of speeds.Film speed is related
to the size of the silver halide crystals in the emulsion or to the
thickness ofthe silver halide layer.X-rays (or light from the intensi-
firing screen; see later discussion) are more likely to interact with
(hit) a large silver halide crystal or the increasednumber of silver
halide crystals in a thicker crystal layer. Thus, degree of film
blacknessfrom a constant exposure is greater for films with larger
silver halide crystals or thicker crystal layers. Fast films, or high-
speed films, have larger silver halide crystals, or thicker layers of
silver halide crystals. Slow films have smaller crystals, or thinner
layers of crystals.The detail of the radiographic image is related to
the speed of the film. Detail is inversely related to speed.Detail is
greater with slow films (small crystals) because the area exposed
by each x-ray is smaller, that is, there is less amplification of
information conferredby eachx-ray (Fig. 1-21).
Focal spot size
Some x-ray tubes have a large and a small focal spot, both of
which are operator selectable.Use of a small focal spot results in
Small 7-1
- crvstat
G Li
Figure 1-21. An x+ay carryinginformationfrom the patient is about to
interactwith an x-rayfilm crystal.On the left (smal/crysta, slow or detailfi mi
t he in f o r m a t i o fnr o m t h e p a tie n twill b e d e p o site do ve ra sm a lle rareathan on
the right \large crystal,fast film). Therefore,detail wlll be better on the left,
but m o r e r a d i a t i o nw i l l be n e ce ssa r yto m a ke th e r a d io g r a p h, becausethe
prob a b i l i toy f a n x + a y l e a vin gth e p a tie n ta n d h ittin gth e cr ystalw i l l be l ess
with small crystalsthan with largecrystals.
Penumbra ,/
Figure 1-22. Theeffectof focalspotsizeon detail.Withlargefocalspots,
the edgeunsharpness,
ot ihe penumbra,is larger.
Thiscontributes to image
unsharpness.
improved detail (Fig. l,-22). The disadvantageof using the small
focal spot is that lower mAs values must be used to prevent the
filament from burning out. With the small focal spot, edges of
anatomic structures are projected much more sharply than with
the large focal spot. This edge unsharpnessis calledpenumbra.In
practice, small focal spots are not used frequently becauseof the
mAs limitations associatedwith them.
Focal spot-film distance
Detail is also related to the FFD. Earlier, the effect of FFD on film
blacknesswas presented.At that time, it was also stated that FFD
affects detail (Fig. 1-23). To summarize what we know about FFD
values:(1) The advantageof keeping FFD long is optimization of
detail; (2) the advantageof keeping FFD short is decreasedradio-
graphic technique (mAs) requirements; and (3) one usually com-
promises, and 40- to 60-inch values are typical.
Object-film distance
The distance of the patient from the film also affects detail. This
parameter is called object-film distance (OFD) (Fig. 1-2a).
Changes in OFD affect detail more than do changes in FFD,
although it should be obvious that both will have some effect on
detail. Therefore, when a patient is radiographed, it is important
to keep the patient as close to the x-ray film as possible.
Large
crvstal
Fi l m
Figure 1-23. The effect of focal spot-film distanceiFFD)on detail.At short
FFDs,x+ays from either side of the focal spot will create a larger area of
edge unsharpness (penumbra) on the fi l m than at l ong FFD s.At s hort FFD s ,
i nformati onfrom the pati ent i s spreadout over a l argerare a of the fi l m
(magni fi cati on)
resul ti ngi n l ossof detai lThi
. si s synonymous w i th photographi c
enl argement. A s a photograph i s enl arged,detai ldecreases bec aus ethe i nfor-
matronts spreadout overa l argerarea.
 RadiationPhysics,RadiationProtection,
Long OF D
Short OFD
Figure 1-24. In this exampe, the film focal distanceis the same in both
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
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
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
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.
Intensifying screens
In reality, the sensitivity of the film emulsion to x-rays is much
lower than its sensitivity to visible light. Therefore, it is more
efficient to convert the x-ray energy into visible light, using the
visible light to expose the film. This is possible becauseof the
property of x-rays by which they cause certain compounds to
fluoresce (see Table i-2). Intensifting screensare used to convert
x-rays into visible light. Intensifizing screensare composed of layers
of phosphorescentcrystals that emit light when struck by an x-ray
(Fig. 1-25). The phosphorescentcrystals of intensiSuingscreens
should not be confused with the silver halide crystals in the film
emulsion.
For radiography, x-ray film is sandwiched between two intensi-
f.ing screensin a cassette(Fig. I-26). The front of the cassetteis
made from a low-atomic-number, low-physical-density material
so as not to absorb a significant portion of the incident x-ray
beam. The cassetteis constructed in such a manner as to comDress
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
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,
Protective layer
Fluorescent laver
,..
Reflective layer
-
\p r u "ti" br""
Figure 1-25. The anatomy of an intensifyingscreen. Intensifyingscreens
are coveredwilh a protectivelayer.Benealhthis is the phosphorescentlayer
w h i c h f l u o r e s c e s( co n ve r tsx- r a ysin to visib lelig h t)wh e n struck by x-rays.
There is a reflectivelayer lying deep beneath the fluorescentlayer,which
reflects light back in the directionof the x-ray film. The film contacts the
protectivelayer.The plasticbase providessupportfor the intensifyingscreen.
and DarkroomTheorv l3
Screen
Figure 1-26, Theanatomy X-rayfilm is placedin a cassette,
of a cassette.
sandwiched between two intensifying
screens. Thisincreases the efficiency
of theentiresystemoverthatachieved if onlyonescreen wereused.Useof
two screens decreases
detarl
in comparison withonlvonescreen, however.
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-
tion being needed to produce a satisfactory radiographic image.
Intensifring screens are used because they can convert a few
absorbed x-rays into many light rays, thereby decreasingthe num-
ber of incident x-rays needed to make a radiograph. This results
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
equlne tnorax.
Intensifring screens originally incorporated calcium tungstate
(CaWO*) as the phosphor, but in the last few years new phosphors
have been developed. These new phosphors are called rare-earth
phosphors, not becausethe components are uncommon but be-
causesome of the componentscome from the rare-earthseriesof
chemical elements, which includes elements of atomic numbers
57 through 71. The x-ray-to-light conversionof these rare-earth
intensifiiing screens is significantly greater than that of calcium
tungstate. For example, one x-ray absorbed in calcium tungstate
producesabout 1000 light rays and the same x-ray absorbedin a
rare-earth phosphor produces about 4000 light rays. Thus, by using
rare-earth intensifling screens,it is possibleto produce radiographs
at mAs settings lower than ever before.
In some instances, where outstanding detail is desired, radio-
graphs are produced without the use of intensif ing screens.This
"nonscreen" technique requires much higher mAs values than do
x-ray
\.*oo""o /
Figure 1-27. Effectof intensifyingscreencrystalsize on detail.Shown is a
screenthat contai nscrystal sof tw o si zes.Thi s i s for i l l us trati on
purpos es
onty, oecause screens are never constructedwith more than one size of
phosphorescent crystal.The crystalon the ieft is smaller,and that part of the
screenw i I be sl ow er (requi remore radi ati onto produc el i ght,bec aus ethe
chanceof an x-rayhittinga sma I crystalis ess) than the rElhtside,where the
crystalsare bigger.An x+ay is shown hitting each crystal.A halo of light is
emrttedfrom eachcrystalThe . hal oi s bi ggeron the fl grhres
t ul ti ngi n a l arger
area of x-ray film being exposed.Therefore,less detail will be seen on the
,ghl becausethe informationbeing recordedfrom the patientis spreadover
a largerareaof the film. Screensfor optimizingdetail,so calleddetail screens,
havesmal l ercrystal sthan regul arspeedscreensbut requi remore radi ati on to
producean acceptableradiograph.
 I4 P HY S I CS
A ND P R IN C IP L ES
O F IN T E R P R E TA TION

screentechniques.However, radiographic detail is superior in non-

screen techniques because the distance that light diffuses from a
crystal in an intensiS'ing screen is larger than the size of the silver
halide crystals in the film, which, in nonscreen techniques, are
exposeddirectly by x-rays. Therefore, information from the patient
is spread out over a larger area of film when screensare used than
with nonscreentechniques.

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
patient, the total volume of tissue irradiated, and the energy of the
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-
tion (seeFig. 1-28). Some x-rays passingthrough the patient will
be aligned with the radiolucent aluminum strips and reach the
film. Some x-rays hitting the patient will be scattered,and the grid
preventsthese from reachingthe film (seeFig. 1-28). These scat-
tered x-rays represent uselessinformation and would only contrib-
ute to fogging of the film if the grid were not present. Some
primary x-rays not scattered by the patient also hit the grid.
Therefore,the number ofx-rays generatedmust be increasedwhen
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
not. This means mAs values 2 to 3 times as large are needed when
grids are used.
The amount of scatter by the patient is a function of the
thickness of the patient. The larger the patient, the more scatter
there will be. Becausesmall patients do not scatter many x-rays,
grids are used only for patients with a thickness greater than
approximately 10 cm.
Figure 1-29. lllustration
of gridratio.Theleadstripsarerepresented asthe
thinblack/ines.Thegridrato is the ratiobetweenthe heghtof the leadstrips
to rl-edistance
oeLween rhem
The size of each lead strip in Figure 1-28 has been exaggerated.
Typically, there are approximately 80 to 160 lead lines per linear
inch of grid; thus, the iead strips are very thin. In radiographs
exposed with a grid, it may be possible to see rhe grid lines if the
radiograph is examined closely. Notice that in Figure l-28, the
more peripheral lead strips are progressively angled in such a
position that planes drawn through each lead strip will intersect at
a point. The distance from the surface of the grid to the point of
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
number of the diverging primary x-rays passing through the grid.
In the previous example, if the lead strips were parallel to each
other, a large portion of the periphery of the diverging x-ray beam
would be "cut off" by the grid.
The grid ratio is another parameter used to describe a grid. Grid
ratio is the relationship of the height of the lead strips to the
distance between them; that is, if lead strips are 5 times as high as
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.

Figurc 1-31. Upside-down grid.lf a focused
grd is usedwiththe upside
down,the primary x-raybeamwill be nearlycompletelyabsorbed,
exceptin
theexactcenterof thegrid.
Whenever a grid is used in the making of a radiograph, each
lead strip casts a linear opaque shadow. If the grid is stationary
during the exposure,the shadows may occasionailybe detected on
radiographs, particularly if there are few lead lines per inch of grid.
If, however, the grid can be made to move during the exposure,
the shadows cast by the lead strips are blurred and cannot be
identified. One disadvantageof a moving grid is that it may make
noiseor vibrate during a radiographicexposure,causingthe patient
to move unexpectedly.
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).
I Distortion
Distortion is due to unequal magnificationof the part being radio-
graphed. This results from one part of the object being closer to
the x-ray tube than the rest of the object (Fig. 1-3a). Interpretation
of radiographscan be compromised if the patient is not kept in
proper relationshipwith the primary x-ray beam.
I Factors affecting contrast
Radiographic contrast refers to the difference in film blackness
between areas in the image. If there were no contrast, all parts
of the patient would be of the same opacity and no individual
structures would be visible. Radiographic contrast depends on
three factors: (1) subject contrast, (2) film contrast, and (3) fog
and scatter.
Figure 1-32. The primaryx-raybeam is not perpendicular
c o u l do c c u ri f u s i n ga g r idth a t is n o t a ffixe dto th e x- r a yta b leor i f the x+aytube
h o u s i n gi s t i i t e d .T h i sr e su ltsln cu t- o ffo f th e p r im a r yb e a ma ndvi sual i zatl on
q r i dl i n e s .
R adi ati on
P hysi cs,R adi ati on
P rotecti on,
and D arkro omTheor v l5
Width of tead
stri p shadow
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
di stances(FFD s).The gri d focus,the poi nt from w hi ch t he dv ergi ngx -ray s
matchexactl ythe di vergence patternof the l eadstr ps i n the gri d,i s s how n i n
thi s fi gure.The anodeshoul dbe l ocatednearthe gri d fo c a poi nt for proper
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.
N ote that even thoughthe focalspot i s too cl ose,the shadow sof the i ead
stri psremai nacceptabl ien the centerof the gri d.A s one progres s es tow ard
the peri pheryof the gri d, how ever,the shadow sof the l ead s tri psbec ome
progressively larger,and cut-off becomessevere.
Subject contrast
Subject contrast is the difference in x-ray absorption through one
part of the subject in comparison with that through another part.
Subject contrast is affectedby (1) thickness differences,(2) physical
density differences,(3) atomic number differences,and (4) x-ray
beam energy (kVp). Thickness, physical density, and atomic num-
ber effects on radiographic opacity and intensity have already been
discussed.The effect of x-ray beam energy (kVp) control on con-
trast has not been discussed,but this is imoortant.
Figure 1-34. In the toppartof this figure,a circularobject is radiographed,
and al l partsof the ci rcl eare the same di stancefrom the a node.The res ul tj ng
to the grid. This radiographrepresentsthe true shape of the object. ln the lower part of this
fl gure,some of the ci rcl ei s cl oserto the anodethan i s the res t of the c i rc l e.
of The resul ti ngradi ographrc i mage of the obl ectdoes not repres entthe true
shapeof the ci rcl e;i t has beendi stortedand i s now teard rops napeo.
I6 P HY S I CS
A ND PR IN C IPL EOF
S IN T ER PR ET A TION

and kVp that will result in an acceptableradiograph (acceptable

film blackness).The major factor in producing an acceptableradio-
graph is just the right intensity of x-rays (x-rays/unit area) at the
film. This can be achievedby many combinations of mAs and kVp;
if high mAs values are used (lots of x-rays generated), then iow
kVp values must also be used to prevent too many of the x-rays
from penetrating the patient and reaching the film. If 1ow mAs
mAs values are used, then high kvp values must be used so that more
of the x-rays penetratethe patient and reachthe film (Fig. 1-35).
Even though there are many combinations of mAs and kVp that
will result in a satisfactory radiograph, the contrast of the image
will depend on whether the kVp is high or 1ow relative to the mAs.
As was noted earlier, contrast refers to the magnitude of the
gradation of film blacknessin the radiograph. In a high-contrast
radiograph, there are mostly black and white opacities and very
few shadesof gray. High-contrast radiographs are also referred to
as having a "short scale" of contrast because everything is either
kvp black or white. Low-contrast radiographs have few blacks and
whites, but many shades of gray; low-contrast radiographs are
referred to as having a "long scale"of contrast becausethere is a
Figurc 1-35, Thereis a rangeof milliampere peak(mAsl
seconds/kilovolt
long scale of shades of gray between the lightest and darkest
thatwillproduce
kVp)combinations radiograph.
a satisfactory Whenlow num-
bersof x+aysare generated,
theirenergymust be high{highkvpi so that portions of the image.
numbers
sufficient reachthe film.Whenmanyx-raysare generated (high In general terms, the reason why low kVp produces greater
mustnotbetoogreator too manywillreachthefilm.
mAs),theirenergy subject contrast than high kVp can be explained by a simple
example (Fig. l-36). The radiograph on the right in Figure 1-36
The ability of an x-ray to penetratetissuedependson its energy has increasedfi1m blackness,and it is overexposedif the radiograph
(seeFig. 1-18). X-rays generatedat higher kVp valueshave higher on the left is satisfactory.This results from the intensity of x-rays
energy. Selecting the proper kVp is one of the most important (x-rays/unit area) being too high beneaththe object on the right.
factors to consider in choosing the exposure factors. If the kVp This can be corrected by using a lower mAs with a higher kVp
is too 1ow, too few x-rays penetrate the patient (radiograph is setting (Fig. 1-37).
underexposed). If the kVp is too high, too many x-rays penetrate
the patient (radiograph is overexposed).The kvp also has an effect Film contrast
on subject contrast. To understand how kVp affects contrast, it is
important to realize that there are numerous combinations of mAs Radiographic contrast is also a function of the type of x-ray film
in use. X-ray film exaggeratessubtle changes in subject contrast.
This is an inherent property of the film and cannot be varied. For

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-
contrast film; a midregion contrast film is satisfactory.
Fog and scatter
The effect of fog is to reduce radiographic contrast. Fog produced
by scattered radiation can be prevented by the use of a grid.
Therefore, radiographs made with a grid have higher contrast than
those that are not. Film can also become fogged by exposure to
pressure or high temperature, or by accidental exposure to light,
such as results from a defective darkroom safelight, or a faulty
light seal around the darkroom door. X-ray film also becomes
fogged spontaneously over time; therefore, an expiration date is
provided by the x-ray film manufacturer.
I Film processing
The most common errors made in radiography of animals are
related to the processingof radiographic film. The darkroom
should be clean, dry lightproof, and uncluttered. It is difficult to
encourage a technician to perform a radiographic examination
carefirlly if the quality of the study is lowered by poor darkroom
facilities. Despite the increased use of automatic processors,many
radiographs in veterinary radiography are still processedmanually.
Developing
The developer reduces exposed silver halide crystals to metallic
silver by supplying electrons to the positively charged silver ions
in exposed silver halide crystals. A 5-minute developing time is
recommended for film processing because it permits a reduction
of required radiation exposure factors (mAs). Film developing is a
chemical process and is therefore dependent on both time and
temperature. Thus, a constant developer temperature is necessary
to obtain consistent film blackness. Generally, this is 68'R but
other times and temperatures can be used.
image on the frlm. Areas where no or minimal silver halide expo-
sure occurred are clear (appear white). fixing time is approximately
twice the development time. The film can stay in the fixer longer,
but underfixing results in a cloudy or milky-appearing radiograph.
Final wash
The film should be washed after fixing to remove excesschemicals
and any residual silver halide still on the film. Failure to wash
adequatelyresults in retained fixer chemicalsreacting with silver in
the film, forming silver sulfide, which causes the film to turn
brown as it ages.When films are processedby hand, they should
wash for 30 to 40 minutes. Excessivewashing or washing in water
that is too warm will result in the emulsion becoming soft and the
entire image "slipping" off of the film.
I Technical errors
Technical errors are commonplace in radiography. These errors at
minimum are irritating when one is reviewing a radiograph and at
worst, they result in the radiograph being totally useless.A com-
plete discussion of technical errors is beyond the scope of this
book. In Table 1-5, the appearance and causes of, as well as
methods to correct, some of the more common technical errors
are presented.
References
1. Roentgen WC: On a new kird of rays. Vet Radiol Ultrasound 36:371-374,1995.
2. Widmer WR, Shaw SM, Thrall DE: Effects of lowlevel exposure to ionizing
radiation: Current concepts and concerns for veterinary workers. Vet Radiol Ultra-
sotnd 37227-t39, 1996.
3. Anon: NCRP Report No. 82-SI Units in Radiation protection md Measurements.
Bethesda,Md, National Council on Radiation Protection and Measurements, 1985.
4. Anon: Title 10, Chapter l, Code offederal regulations-Energy.part20, Standards
for Protection Against Radiation. In United States Nuclear Regulatory Commission
Rules and Regnlations. Washington, DC, US Gort prnting Of8ce, 1995, pp 20-27.

Fixing
The fixer converts undeveloped silver halide crystals on the film
into a soluble compound. Fixer clears undeveloped, unexposed
silver crystals from the film. This leavesthe silver as a permanent
!.
Hall E|: Radiation protection. In Hall EJ (ed): Radiobiology for the Radiologist,
4th ed. Philadelphia, lB Lippincott, t994,pp 453-467.
6. Anon: NCRP Report No. l07-Implementation of the principle of As Low As
Reasonably Achievable (AI-{RA) for Medical and Dental personnel. Bethesda. Md,
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 1-38 Figure 1-39

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

ffi Basic Ultrasound Physics

. William Tod Drost

Use of ultrasonography in veterinary practice is increasing at a
rapid rate. A basic understanding of the physics of ultrasound is
important as it helps explain some of the limitations and artifacts
encountered.Medical sonography usessound wave echoesto create
images, and it is the only diagnostic imaging modality that does
not use electromagnetic radiation. In this chapter, the basics of
gray scale ultrasonography are discussed.Doppler techniques are
not discussed here. Referencesare available for the reader who
wants more information about Doppler ultrasonography.t '
Velocity (mm/p.sec) : frequency (MHz) X wavelength (mm)
For a constant velocity, frequency and wavelengthhave an inverse
relationship so that as frequency increases,wavelength decreases,
and vice versa. Within soft tissue, the velocity of sound is 1.54
mm/psec (1540 m/sec).1The velocity of sound in soft tissue is
important becauseultrasound machinesuse this constantvelocity
for all of their calculations.
Diagnostic ultrasound machines operate in pulsed mode for
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
I ultrasound waves
Sound travels in waves and carries information from one place to
another. It transmits energy by alternating regions of low pressure
(rarefaction) and high pressure (compression).'' Unlike light and
radio waves, sound waves require a medium through which to
travel (sound cannot be propagated in a vacuum).t Frequency,
wavelength, and velocity are parameters that are used to describe
sound waves;these terms are also used in referenceto electromag-
netic radiation (seeChapter 1).
Frequencyis the number of times a wave is repeatedper second.
One wave or cycle occurs when pressure starts at a normal value,
increasesto a high pressure value, decreases(passing the normal
value) to a low pressure value, and then returns to normal (Fig.
2-1). A cycle may also be defined as the combination of compres-
sion and successiverarefaction.TFrequency units are expressedin
hertz (Hz) where 1 Hz equals one cycle per second. Diagnostic
ultrasound tlpically uses frequenciesbetween 2 megahertz (MHz)
and 10 MHz (1 MHz -- 1,000,000Hz). The audible range of
sound for humans is 20 Hz to 20,000Hzt; sound lessthan 20 Hz
is infrasound, and sound greater than 20,000 Hz (0.02 MHz) is
ultrasound.t
Wavelength is the distance traveled by a sound wave in one
cycle. In ultrasonography, it is expressed in millimeters (mm).
Wavelengthis important for image resolution and is discussedlater
in the text.
Velocity is the rate at which sound travels through an acoustic
medium; it is determined by the physical density (mass per unit
volume) and stiffness(hardness)of the transmitting medium.r'n
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
or bone well (almost all sound is reflected), the velocity of sound
within thesetissuesis not a factor in diagnostic ultrasound. Velocity
is also related to frequency and wavelength of a sound wave in the
following equation:
of the time listening for returning echoes. The pulse repetition
frequency (PRF) is the number of times this pattern of sending
and listening is repeated within 1 second.' The length of space in
one pulse of ultrasound is calledthe spatialpulsed length (SPL).If
a sound wave has a wavelength of 0.5 mm and three pulses are
sent each time, the SPL is 1.5 mm. SPL is important for axial
resolution.
It is important to consider how echoesare formed becauseit is
the echoesthat contain the information about the structures being
imaged. We must consider the interface that causesthe echo reflec-
tion and the angle at which the sound wave strikes the reflector, or
the angle of incidence.
Acoustic impedance of a tissue is the product of the tissue's
physical density and sound velocity within the tissue.l,3
Acoustic impedance (Z) : velocity (u) x tissue density (p)
Changesin acousticimpedancefrom one tissueto another deter-
mine how much of the sound wave is reflected and how much is
transmitted into the secondtissue.The amplitude of the returning
echo is proportional to the difference in acoustic impedance. If
trvo tissueshave no difference in acoustic impedance, then no echo
is created.If a large difference in acoustic impedance existsbetween
two tissues,then almost all of the sound is reflected.l To calculate
the percentageof the sound wave that is reflected and transmitted,
the following formulas are useda:
yo reflected: (2, - Z,)l(2, + Z) X 100
o/otransmitted : 100 - o/oreflected
In the first equation just above, Z. is the acoustic impedance of
the second tissue, and Z, is the acoustic impedance of the first
l|ililt t | | | I I t lililt | | | | | |
Figure 2-1. An ultrasoundwave depictedas a sine wave (top) and as a
series of compressionand rarefaction(bottom).One wavelength (\) is the
distancebetween two successivepeaks or valleysof the sine wave or be-
tween two successivecompressionor rarefactionevents.

20
 B asi cU l trasound
Phvsics 2l

Table 2-1. Velocity of sound in commonly encountered

tissuesl
l]ssue Velocity {mm/psec}
Air 0. 331
Fat 1. 450
Water (50"C) 1. 540
"Soft tissue" 1. 540
Bra in 1 E A1

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

tissue. The approximate acoustic impedance of commonly encoun-

tered tissues is listed in Table 2-2. lJsing the values in Table 2-2,
one can ascertain that the largest difference in acoustic impedance
occurs at interfaceswith bone and gas.Theseinterfaces,soft tissue-
gas and soft tissue-bone, reflect almost all of the sound wave; thus
little or no sound wave passesthese boundaries. This nearly total
reflection creates an acoustic void or shadow deep to the tissue
interface. Without placement of acoustic coupling gel between the
patient and the transducer, the soft tissue-gas interface (created
principally by gas trapped between the skin and transducer) would
because
of reflection
of a1lof the oncoming
iffiTj#lting
Angle ofincidence is the angle at which a sound wave encounters
a medium. If the angle of the sound wave is perpendicular (90
degrees)to the reflector, the reflected portion of the sound wave
travelsopposite (180 degrees)to the direction ofthe initial sound
wave, and the transmitted portion of the sound wave continues in
the same direction as the initial sound wave (Fig. 2-2A). If the
angle of incidence is not perpendicular,then the angle of re-
flectanceequalsthe angle of incidence (see Fig. 2-28). It is esti-
mated that ifa sound wave strikes a reflector farther than 3 degrees
from perpendicular, then the reflected sound will not reach the
transducer.l The angle of transmission on a nonperpendicular
sound wave depends on the relative acoustic impedance of the two
media. Any sound wave that is not reflected toward the transducer
will not be recorded. Remember that the amount of reflected and
transmitted sound dependson the differencesin acousticimped-
ance of the two media.
f Transducers
A transducer is a device that converts one form of energy to
another.l'1'r0In ultrasound imaging, this meansconvertingelectric
activity into sound waves,and vice versa.This conversion is accom-
plished in a piezoelectric crystal. As an electric charge is applied to
a piezoelectric crystal, the material deforms and creates a sound
Table 2-2. Approximate acoustic impedance in
commonly encounteled tissuesl, a
l'issue Acoustic impedance(rayls)
Air 0.0004
' current
Fat 1. 38
Water (50"C) 1. 54
Brain | .5tt
Blo od 1. 61
Kid ne y 1. 62
Liver t.oc
Mu scle 1. 70
Lens of eye 1. 84
Bo ne (sku ll)
7. 8
Me d iu m2
Figure 2-2. The angleof incidence is the angleat whicha soundwave
encounters a medium. lf theangleof thesoundwaveis perpendicular {90.)to
the reflector/A/,the reflectedportionof the soundwavetravels.oooosite
i180')to thedirection
of theinitial soundwave,andthetransmitted portion
of
thesoundwavecontinues in the samedirectionasthe initial
soundwave.lf
the angleof incidence is not perpendicular1Bl,thenthe angleof reflectance
equalsthe angleof incidence; the ange of transmittancedepends on the
differencein acoustic
impedance of Medium1 versusMedium2.
wave.l0Conversely,when sound waves are applied to piezoelectric
crystals,they produce an electric signal. Therefore, the iame crystal
is used to send and receive sound waves but it cannot send and
receive signals at the same time.l A typical ultrasound transducer
emits sound waves less than lolo of ihe time and receivessound
wavesmore lhan 99o/oof the time.3,6
Ultrasound transducers come in many shapes and sizes. The
selection of the proper transducer depends on ihe physical proper-
ties of the transducer and the characteristicsof the anatomic reqion
to be imaged.
Mechanical transducers are either single- or multiple-crystal de-
vices in which movement of the crystal(s) actually eafectscoverage
(and imaging) of a volume of tissue.The crystal elementsoscillaie
back and forth, or are continuously rotated within the head of the
transducer.The elementsare immersed in acousticcoupling me-
dium within the transducer assemblyso that only the internal"parts
of the transducer move while the outer surface remains stationary
againstthe patient. Mechanicaltransducersproduce sector (pie)-
shaped images.Owing to their moving parts, mechanical transduc-
ers are subject to wear.3
Electronic transducers,also called array transducers,are com_
posed of several small elements in various arranqements.The
elements_maybe arrangedin a line or rectangle(lin-eararray), in
a curved line (convex array), or in concentric ring fashion (annular
array).r0The elementsthat composethesetransducersare electron-
ically fired in various .eqo.r..i to create different-shaped images
or to focus the sound beam at specilicdepths.Electronictransduc-
ers do not have moving parts nor do they need an internal acoustic
coupling medium. The most commonly used tvpe of transducer in
ultrasound machines is the electronic iransducer.
TWo basic shapesof ultrasound images are commonly encoun-
tered. Images made in sector fashion are pie-shaped (see Fig. 2-7)
and imagesmade in linear fashion are rectanguiar(see nig. Z-S).
Sector images are produced from transducerswith small footprints
(amount of transducerthat contactsthe patient); linear transducers
usually have larger footprints. For thoracic imaging, sector-shaped
transducers are preferable becauseone must u.ql.ri.. images fiom
within the intercostal spaces.For abdominal imaging, the use of
22 P HY S I CS S IN T ER PR ETA TION
A ND PR IN C IPL EOF
sector or linear transducersis often dictated by the personal prefer-
ence of the sonographer.
Transducersare classifiedby the location of the crystals on the
scan head. In end-fire transducers,the elements are located on the
end of the probe, but side-fire transducer elements are found on
the side ofthe probe, 90 degreesfrom the end. Side-firetransducers
are used in cardiac and abdominal imaging; end-fire transducers
are used for intracavitary imaging such as large animal (per rec-
tum) reproducliveexaminations.
Resolution is the ability of an ultrasound machine to distinguish
echoesbasedon space,time, and strength.I0The better the resolu-
tion, the more likely the sonographer is to identifr abnormalities.
As the frequency of an ultrasound transducer increases,the resolu-
tion increaies. Sonographerswant to use transducers of the highest
possiblefrequencyfor imaging to get the best possibleresolution.
Axial resolution is the resolution of two separatereflectors along
10
the direction in which the sound wave is traveling.6'z It is equal
to half the spatial pulse length (SPL). Earlier in the chapter, we
learned that the SPL is the length of spaceover which the pulse of
a sound wave travels. When two reflectors are separated by a
distance that is greater than half the SPL, the echoes from these
two reflectors do not overlap as they return to the transducer and
are interpreted as separateechoes(Fig. 2-3). If the distancebetween
the reflectors is lessthan half the SPL, the returning echoesoverlap
and are interpreted as a single echo. Because transducers with
higher frequency have shorter SPL, axial resolution is improved.
Lateral iesolution is the resolution of two separate reflectors
oeroendicular to the direction in which the sound wave is travel-
ing.'''o This is determined by the ultrasound beam width.' To
re-ognize the objects discretely,the beam must be narrower than
the distancebetween the objects. The width ofan ultrasound beam
decreaseswith increasing frequency.In a focused ultrasound beam,
where the width of the beam is restricted, the lateral resolution is
best at the focal point of the ultrasound beam becausethis is the
narrowestpart of the beam.
A
; SPL
Y is filtered from the image. If the reject is set too high, some of the
A to determine the amount of time it takes to receive echoes.The
<o.ssPLI
B from the reflector to the transducer. This assumesthat the sound
Figure 2-3. Axal resolutiondependson the spatialpulse length /SPLIof
the soundwave and the amountof separationof the reflectors lf the reflectors
are greater than 0.5 times the SPL (A), the structuresreturn two dlscrele
echoes,as illustratedbV the two separatearrows' lI the reflectorsare less
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.
Depth of sound wave penetration varies inverselywith fre-
quency.THigher frequency transducers are best for structures that
are close to the surface; lower frequency transducers are best for
deeperstructures.The choice of ultrasound transducervarieswith
the experienceof the sonographer.As a guide, one should start
with a higher frequency transducer (becauseit has better resolu-
tion) and switch to a lower frequency transducer if deeper struc-
tures are not well imaged.
I Basic scanner controls
The power control modifies the intensity of sound output by the
transducer.r This is accomplished by adjusting the voltage applied
to the piezoelectriccrystal.Increasingthe power leadsto a uniform
increasein the amplitude of returning echoesand therebyincreases
overall image echogenicity(brightness).Keeping the power level
low heips improve image resolution and helps prevent artifacts.3
Therefore,it is preferableto use the time gain compensationcurve
to modify the strength of returning echoesrather than using the
power control.
Gain affects the amplification of the returning echoeswithin the
receiver.Increasingor decreasingthe gain increasesor decreases
the brightnessof the image displayedon the screen.If the gain is
too low, the subtle parenchymal detail of tissue is lost. If the gain
is too high, the image is too bright and contrast resolution is lost.
A common analogy is to compare the gain knob on the ultrasound
machine with the volume knob on a stereo.At low settings, subtie
music cannot be heard, and at high settings, the music is too
offensive to be enjoyed.
TCG stands for time gain compensation. Becausesound waves
lose intensity as they travel in tissue, echoesreturning from deeper
tissues are weaker than echoesreturning from tissuescloser to the
ultrasound transducer. To make an image uniform in brightness,
it is helpful to amplifr the echoesfrom deeper tissuesto a greater
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
acoustic, is not useful and can subtly degrade the image. Many
machines allow the user to selecthow much of the 1ow-levelnoise
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
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-
ducer to the reflector and back is two times the actual distance
wave travels in a straight line with no side trips along the way.
Two modes of echo display are commonly used in ultrasonogra-
phy. These are brightness mode (B-mode, B scan, or gray scale)
and motion mode (M-mode). B-mode is the most commonly used
format and is used in both abdominal and cardiac imaging. M-
mode is used only for echocardiography.

l-mode imagescomprisea collection of dots that correspondto
-,-. amplitude or strength of the returning echo.u'rrThesedots are
:-sllayed on a black background,and the brightnessor gray scale
, . fie dot is highest (whitest) for the strongest returning echoes.
-::: depth of the structure returning the echoesdeterminesthe
: -.'ition of the dots relative to the position of the transducer.
:.iritiple thin scanlines make up a completeimage so that B-mode
-::aqeslook like a slice of tissue.t
\I-mode records a thin section of an ultrasound image over
:-:re. On an M-mode image, the depth of the image is displayed
--: the vertical axis, and time is displayed on the horizontal axis.
-::e brightnessof the dots is proportionate to the strength of the
:e:urning echoes,as it is in B-mode. While holding the transducer
:tationary, one can evaluate how far a structure moves over a
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.
Image orientation varies with the structure that is being imaged.
For cardiac imaging, the right side of the screenis cranial (toward
the patient's head) with long axis images. For all other structures,
the Ieft side of the screen is cranial and the top of the screen is
dorsal (toward the patient's spine) for longitudinal images. For
transverseimages,the left side of the screenis dorsal.
I Principles of interpretation
Echogenicity relates to the relative brightness of a structure. An-
echoic structures have no echoes within them and appear black.
\\tren the echogenicity of two structures is compared, the darker
structure is hypoechoic and the brighter structure is hyperechoic.
If the structures have the same degree of brightness, they are
isoechoic to one another. Becausetissue derangementsresult in
changesin echogenicity,it is important for sonographicpurposes
to know the relative echogenicitiesof abdominal organs. Table 2-3
lists abdominal organs in order of their relative echogenicity.l3,14
Detecting changesin echogenicity is diffrcult, and accurate detec-
tion is related to the experienceof the sonographer.One should
compare multiple abdominal organs with one another to determine
which are truly abnormal. Additional complexity results from the
fact that machine settings may alter the echogenicity of an organ.
As an ultrasound beam travels through a medium, it is attenu-
ated. In other words, it iosesstrength as it travelsthrough tissue.
The amount of attenuation is determined by the distance traveled
and the frequency of the sound wave. The amount of attenuation
approximates0.5 decibels (dB)lcmlMHz over a round-trip dis-
tance.3Sound beams of higher frequency are more attenuated
than lower frequency sound waves.Attenuation of the sound wave
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
called absorption.It is the dominant component of attenuationin
sofl tissue.8The conversionof sound wavesto heat occursorimarilv
Table 2-3. Relative echogenicity of commonly
encountered structures in order of decreasing
echogenicity3,13
Bone,gas , or gan boundar ies
Structuralfat, vesselwalls
Renals inus
Prostate
Spleen
Storagefat
Liver
Renalc or t ex
M us c le
Renalm edulla
Bile, ur ine
B asi cU l trasound
Phvsics 23
via frictional forces.3With diagnostic ultrasound machines, the
relative amount of sound absorbed is very low and the temperature
changeis insignificanland imperceprible.
Reflection of the sound beam contributes to attenuation. As
the sound wave encounters tissue interfaces of different acoustic
impedance, a reflection is generated. Only reflections that return
to the transducerare used for image formation. The scanningof
structures from different anglesmay enhanceimage quality if more
echoesare returned to the transducer from different angles.
Scattering occurs when sound waves encounter smal1,irregular
surfaces.This occurs mainly within the parenchyma of organs and
is responsible for the texture of the internal organs. As the fre-
quency of a sound beam increases, the incidence of scattering
increasesas well.
I Artifacts
Misrepresentation of structures caused by some characteristic of
the imaging technique is an artifact. In diagnostic radiology, arti-
facts hinder evaluation of the imase and are undesirable. Ultra-
sound artifacts are not always und'esirableand may actually en,
hance evaluation of structures by providing insight as to the
composition of the structures.For instance,sonographicimaging
of a fluid-filled structure (versus a hypoechoic tissue mass) reveals
enhancementof soft tissuesdistal to the fluid-filled structure. Some
basic ultrasound artifacts are discussedin this section of the text.
Reverberation artifacts are multiple hyperechoic foci that occur
at regular intervals on the image. Reverberation occurs when the
sound wave encounters an area of high reflectivity and the sound
wave is reflected back toward the transducer.t. When the reflected
sound wave encounters the transducer, most of it is reflected back
into the tissues where it again encounters the area of high reflec-
tivity. This cycle of bouncing between the transducer and the
patient continues many times, resulting in the regularly spaced
hyperechoic foci on the screen (Ftg. 2a). The distance between
the transducer and the highly reflective surface determines the
spacing of the hyperechoic foci. A common causeof reverberation
artifactsin abdominal sonographyis intestinal gas.
Mirror-image duplicate structures that are normally present on
one side of a strong reflector sometimesalso appear on the other
sideofthe reflector(Fig. 2-5). This is most commoniy encountered
when the liver is imaged with the diaphragm-lung interface aiting
as a highly reflective structure.Is When the gallbladder is used as
the "duplicated" structure, the artifact is explained. Normally, the
sound wave is sent toward the gallbladder, is reflected back toward
the transducer,and is recorded on the screenaccording to how long
it took the echoesto return to the transducer. For the artifactual
off the diaphragm-lung interface toward the gallbladder,and echoes
off the gallbladderback toward the diaphragm-lung interface,
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
artifactual gallbladder is misrepresentedon the screen.
Side lobes and grating lobes are secondarysound beams that
emanatein a different direction than the orimarv sound beam.t'tu
Side lobes are associatedwith all transducers and originate from
additional mode vibrations of the piezoelectric crystal; grating
lobes emanate from array transducers.In each instance, these lobes
result in an error in positioning of the returning echo (Fig. 2-6).
The side or grating lobes are weaker than the primary sound beam;
these lobes must encounter a highly reflective surface and be of
sufficientintensity to be noticed.rT't8
Slice thickness artifacts are most commonly noticed in associa-
tion with the urinary bladder and the gallbladder. In these struc-
tures, slice thickness artifacts mimic the presence of sludge or
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
urinary bladder is imaged, for example, part of the thickness of
the primary sound beam is involved in imaging the urinary bladder
wall while the other part is imaging the anechoic urine. The
computer averagesthese two parts to create the pseudo-sludge
artifact. The surface of the pseudo-sludge is usually curved, but
the surfaceof real sludgeis flat.t7
Refraction occurs as the sound wave traversestissuesof different
acoustic impedance.As the sound wave moves to the new medium,
the sound wave is bent. The bending of the sound wave may result
in the display of organs in improper locations. Although organ
Figure 2-5. A mirror image artifactof a dog's gallbladderwas createdat the lung/diaphragm
artifactualgallbladderis in the far tield (GBa).The lung/diaphragm
the route that the sound wave travels (white arrows)to make the artifactualgallbladder.
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
Figure 24. On the /eff is a reflectionartifact that was creared by
submergi nga tongue depressori n a w ater bath. The to ngue depres s or
was 1 cm from the transducerand the artifactualtongue depressorswere
positioned2 and 3 cm from the transducer,respectively.Ihe large tick
markson the /eft side of the imageare at 1 cm intervals.On the rErhtis a
schematicof the sound wave (arrows)reflectingback and forth between
the tonguedepressor and the transducer.
duplication due to refraction artifacts is described in people,r, it
does not occur commonly in animals. Refraction artifacts may lead
to measurement errors.
Edge-shadowingartifacts are refraction artifacts that are created
when sound wavesare bent as they tangentially encounter a curved
surface (Fig. 2-B).i:, zoAnechoic regions are present distal to the
curved surfacesto which the bent sound waves should have trav-
eled. This artifact commonly occurs when the gallbladder, urinary
bladder, or kidneys are imaged.
Acoustic shadows are regions of decreasedechogenicity distal to
structuresof high reflectivity (Fig. 2-9).re 17,rsIn thesesituations,
interface.The real gallbladder(GBr)is in the near field ano rne
interfaceis the curved,thin white irne separating ihe two gallbladders. The schematicshows
Becausethe ultrasound-machine cannot detect that the sound wave
(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-
sorbed.An insufRcientquantity of echoesreturned from the loca-
tion distal to the strong reflector make these regions appear an-
echoic (black).6 Naturally occurring acoustic shadows are found
at soft tissue-gas (bowel, lung) and soft tissue-bone interfaces;
pathologic acoustic shadows are most common with renal, cystic,
or cholecystic calculi.
Acoustic enhancement is a region of increased echogenicity
behind structuresof low attenuation (Fig. 2-10).r'Z''8This results
in areas of increased echoeenicitv distal to these areas of low
attenuation. The two most common sites for acoustic enhance-
ment are distal to the gallbladder and the urinary bladder. To
better understand this artifact, one must consider the acoustic
shadowing causedby the gallbiadder. Sound wave 1 travels through
the liver and the bile within the gallbladder, then back inro the
liver. Sound wave 2 travels only through liver tissue. As sound
wave 1 passesthrough the bile, it is less attenuatedthan sound
wave 2 (as it passesthrough liver). Thus when sound wave 1
reentersthe liver, it has a higher intensity and returns stronger
echoesto the transducer.

Figure 2 - 9 . A n u l t r a s o un im d a g eo f a d o g ' su r in a r yb la d d e illu

r strati ngacousti cshadow i ngcausedby sand-i ke cystc cal cul iThe
. sand-l i ke
cvsti cca l c ulare
r rne
I norr h ' n a r a n h n i ^c + r' ' 1 ' r o ln th e d ista la sp e cto f th e u r in a r yb la d der.
The bl ackareabel owthe sandl rkecysti ccal culrepresents the acousti cshadow i ng.

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.

Buddemeyer EU: The physics of diagnostic ultrasound. Radiol Clin North Am

-.
:::9 1 -4 0 2 ,1 9 7 5 .
W Ouestions
:. Laing FC, Kurtz AB: The imporlance of ultrasonic side-lobe artifacts. Radiology
=5 r 6 3 7 6 8 , 1 9 8 2 . l. Which imaging modality does not use electromagnetic radia-
: Herring DS, Bjornton G: Physics, facts and artifacts of diagnostic ultrasound. Vet tion?
..:: \orth Am Small Anim Pract 15:1107-1122,1985. A. Computed tomography
- ?orvis RL; Ultrasound science for the veterinarian. Vet Clin North Am Small B. Nuclear medicine
---:r Pract 2:3-27, 1986. C. Magnetic resonanceimaging
: -{renkau FW: Ultrasound. In Kremkau FW (ed): Diagnostic Ultrasound Princi-
D. Radiography
:.': :nd Instrumentation, 5th ed. Philadelphia, WB Saunders, 1998. E. Ultrasound
: Carlsen EN; Uitrasound physics tor the physician: A brief review. i Clin Ultra-
.. ::J 3 :6 9 -7 5 ,1 9 7 5 . 2. What is the velocity of sound within soft tissues?

. {:emkau FW; Transducers.In Kremkau FW (ed): Diagnostic Ultrasound Princi-

: :: :nd Instrumentation,5thed. Philadelphia,WB Saunders,1998.
3. \n/hen a sound wave moves from one tissue to another, what
determines how much of the sound wave is reflected and how
Lantanen NW, Ewing RL: Principles of ultrasound application in animals. Vet
much is transmitted?
: ::rl 1 2 :1 9 6 -2 0 3 1
, 981.

-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.

10. 'tArhat is the white artifact below the sallbladder noted in

8. Determine the distance betrveena reflector and the ultrasound Figure 2-i0?
transducerif it took 6.495 psec for the echoesto return to the
transducer in soft tissue. Answers begin on page727.

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
Table 3-1. Representative GT values (in Hounsfield
unitsl of different tissues/substances within the body
Body part CT value
White matter 30 (35")
Gray matter 35 (42*l
Cere bro s pinal
f luid 6-10
He morrh age,ac ut e ( whole blood) 52
Blo od clot 50-80
Plasma 25
Water 0 New techniques in CT have allowed for faster imaging and
xCTvaluesof white and gray matter will increaseafter contrastenhance-
ment. Grav matter receivesfour times the blood flow that white matter
does,so gray matter will be more attenuatingjust after deliveryof the
contrastmediumto the brain.Edemawill decreasethe attenuationcoeffi-
cient of the affectedareaproportionalto the amount of water within the
edematousstructure.
Acquisition of CT images is dependent on the rotation of an x-ray
tube around the patient and the acquisition of a seriesof x-ray
projectionsusing rotating (third-generation)or stationary(fourth-
generation) x-ray detectors.l As in conventional radiographS the
x-rays either pass through the patient or are attenuated. This
attenuation is dependent on the energy of the x-ray, the electron
and physical density of the material within the patient, the thick-
nessof the patient, and the effective atomic number of a particular
substancewithin the patient. This transverse raw data set is then
reconstructed using the mathematical algorithm of filtered back-
projection, and an image is produced.t
A CT image is a matrlx of squares,each having a unique degree
of blackness,depending on the attenuation of photons from a
given location within the patient. Standard CT scannersacquire
data from a particular tissue thickness with each transverse slice.
All of the attenuation information that is collected within a given
voxel (i.e.,volume elementof the associatedpixel) is averaged,and
this averagedgray scalevalue is then displayed.This averagedgray
scalenumber can lead to erroneousinterpretationbecauseof vol-
ume averaging resulting from the particular volume or thickness
of a given slice of information. In other words, if a voxel contains
a very opaque structure and a very lucent structure, the end-result
blackness (physical attenuation or CT value) of the voxel will be
an intermediate shade of gray. Thus, volume averaging can artifi-
cially raise or lower a structure's attenuation value, and thereby its
appearancein the image.r''? As has been mentioned, the number of
\-rays attenuated by the patient is affected by a variety of factors.
\\tren the computer reconstructsthe images,the image voxel values
are normalized to the linear attenuation coef6cient of water. These
ralues are expressedin Hounslield units (HU).+ Water has an HU
of zero, cortical bone has an HU of + 3000, and air has an HU
of - 1000. Different organs and materials within the body have
;haracteristicHU values (Table3-1).
One can manipulatethe valuesof the gray scalethat are assigned
:o the CT image. The window width describesthe range of CT
lalues assignedto the gray scalewithin the image. A wide window
rridth would be 1000, whereas a narrow window width would be
150. A wide window width is used when an extreme spectrum of
-:hvsicaldensity (and therebyHU) is being imaged (e.g.,the lung).
'r\'ith a wide window, structures with only slight differencesin HU
-"alueshave the same appearance.A wide window should not be
used to discriminatebetweentwo similar (in terms of HU) struc-
r:res. A narrow window width is used when a smaller sDectrum
..: physical densities (HU) are close to one another {e.g., when
;rtferentiating gray and white matter within the brain, or brain
;dema from neuropil).6' Window width is similar to radiographic
.lrntrast. Imageshaving a wide window have a long scaleof con-
'CT r.alue(Hounsfield unit) : l(pmaterial pwater)/(pwater)l X 1000, where
= linear attenuation coefficient.
lm aging 29
trast (low contrast), and images having a narrow window have a
short scaleof contrast (high contrast).
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
window width is 200, the range of HU values that would be
displayed would include -50 to 150 HU. Any structure with a
Hounslield unit of - 50 or below would appear totally black, and
any structure with a Hounsfield unit of 150 or above would appear
totally white.
coverageof larger fields-of-view. These new techniques are based
on the use of slip-ring technology, wherein the x-ray tube (and
detectors in a third-generation scanner) can rotate without having
to stop to resetafter eachslice(return from the 360-degreeposition
backward to 0 degrees) for the next revolution. This has allowed
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-
ous acquisition of data while the patient is continuously moved
through the gantry at a constant table speed.The pitch of the scan
is dependent on the slice thickness/table speed, so that a slice
thicknessof 5 mm and a table speedof 5 mmisec would equal a
pitch of 1. Higher pitches of two will result in possible artifacts
during the reconstructionprocess.This volume of information is
reconstructedusing filtered backprojection and 360-degreelinear
interpolation. A third recent advance in CT technology in which
there are multiple rows of detectors is called multichannel com-
puted tomography. With the use of this technology, becausemulti-
ple detector rows are used, more than one image siice can be
acquired at a time. These last two technologies have allowed for
rapid acquisition of large volumes of informition in a very short
time, which has contributed to the advancementof CT angiography
and the three-dimensionalimaging of largebody parts. Application
of these techniques to veterinary medicine enablespatient imaging
without the need for general anesthesia.
Magnetic resonance imaging
MR imaging is the latest cross-sectional imaging modality to gain
wide acceptance,particularly in the area of soft-tissue,bone mar-
row, and neurologic imaging.s'0 Advancesin MR imaging have
allowed rapid imaging of small parts with high inherent contrast
resolution. The mechanism for acquisition of data is completely
different from any other imaging modality. The reader is encour-
aged to consult other referencesfor a complete explanation of MR
physicsand imagingprinciples.,. 4
The fundamentals of MR are dependent on several inherent
nuclearphenomena.The nucleus.oniirt, of protons and neutrons.
Both protons and neutrons have a property calledspin, or angular
momentum. Becauseof its positive electric charge, the proton
behaves like a magnet, and it establishesa small magnetic field
about itself. This property of behaving like a magnet and generating
a spin is called a magnetic dipole. If there is an odd number of
protons, the unpaired proton will exert a magnetic dipole with a
discrete strength and direction (a vector quantity). The hydrogen
atom is the most abundant nucleus in the body with an unpaired
proton, and therefore is the nucleus that is most commonly imaged
using MR. Other potential nuciei with odd proton numbers that
could be imagesin MR include t,C, ,.Na, and ,eF.
With the patient in a high-strength external magnetic field, the
proton magnetic dipoles align themselveswith the long axis of the
magnetic field (usually along the axis of the patient's body, defined
as the z-axis). A net magnetic moment is then established(Fig.
3-2). Another property of individual protons is that they can
absorb energy from externally emitted radiofrequency waves. This
absorbed energy causesthe individual proton's vector direction to
move out of alignment with the external magnetic field (Fig. 3-3).
The "excited" proton then starts to rotate around its original spin
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

,'i the axis or directionof Bo (z-axis).Most

l,,,rll3l, of the protonsw i l l al ignthems el v esi n
t ''
t,:iiill
, ,, the paral elor l ow er energys ra1e,bur
sorre w i l l al i gntherrsev es i n the anti -
s,l paral l elor hi gherener gys tate.The net
X magneti zati on vector i s determi nedby
the summati onof al l of the i ndi v i dual
K proto^sw i th n rhe areaol i nteres t.C on-
ceptual l y,;t i s easi erto thi nk i n terms
of a l argenet magneti cmoment w hen
expl ai ni ng the effectsof radi ofrequenc y
pulseson the net magneticmomeft (M)
versusthe i ndi vi duai protons ,al though
the i magi ngmagnettak es i nto ac c ount
di scretenumbersof i ndi v i dualprotons
w i thi nthe fi el dof vi ew.

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
the angular frequency. This angular frequency is directly propoF
tionate to the magnetic field strength, Bo,by the equation:
oo (angular frequency) :
1 (gyromagnetic ratio) X Bn (external field strength in Tesla)
As angular frequency is measured in radians per second and as
there are 2rr radians in a complete rotation, the equation can be
rewritten in terms of the precessionalfrequency expressedin cycles
per second,or Hertz, as follows:
fo (precessionalfrequency) :
1l2r x Bn (external fie1d strength in Tesla)
where the frequency of precession (fo) is also called the resonance
frequency,or the Larmor frequency.For protons, 1l2r ls a constant
and is equal to 42.58 MHz/Tesla. This means that in a static
magnetic field of 1.5 Tesla,the protons will precesswith a frequency
of 63.87MHz (1.5 x 42.58).
The net magnetic moment (Mz) is aligned with the external
magnetic field. If electromagnetic radiation is applied as a short
radiofrequency pulse, the magnetic moment can be reoriented to a
new direction out of the z-, or longitudinal, plane and into the x-y,
or transverse,plane. For the protons within the subject to absorb
the radiofrequency photons of energy (and thereby move from a
parallel to a higher energy, and less stable, anti-parallel state), the
radiofrequency pulse must be equai to the precessionfrequency of
the protons within the subject. Once the proton has been reori-
ented in a different plane owing to the absorption of the radiofre-
quency pulse, it will again attempt to reach the lower energy state.
This processof relaxation is dependent on severalfactors, including
magnetic field strength, spin interactions, magnetic field inhomoge-
neities, and the presenceof paramagnetic materials and the envi-
ronmental lattice within which the proton is found.
Think of the simplest MR experiment as the patient being placed
inside the magnet, with a series of radiofrequency waves (pulses)
being used to excite the given nuclei; then the excitation pulse is
turned off. The receiver coils are turned on to "listen" for the FID
signal generatedby the excited protons as they lose phasecoherence
and return to their lower energy state. These latter two steps are
repeated a number of times and the volume of raw data is then
availablefor reconstruction into a given imaging plane. This repre-
sents an oversimplification of the process; further explanation is
necessaryfor defining the MR characteristics of different tissues.
issuesofk spaceand Fourier transformationare not discussedhere.
TI relaxation (spin-lattice or longitudinal
relaxation)
T1 relaxation can be defined as the time (msec or sec) required
-or protons to recover63.20/oof their original Mz value in the z-
lirection after the application of a radiofrequency pulse that rotates
:he original net magnetic moment by 90 degrees.Becausethis
-nvolvesthe releaseof energy from the protons moving from the
ercited (anti-parallel)state to the lower energy (parallel) orienta-
::on, the longitudinal (z-direction) magnetizationis gradually re-
;overed, so T1 relaxation is also referred to as longitudinal relax-
.:ilon. Additionally, the T1 relaxation is dependenton the energy
:rchangebetweenthe excitedprotons and the surrounding molecu-
-ar lattice, so another name for T1 relaxation is spin-latticerelax-
::;on.
T1 relaxation is dependent on severalfactors, including molecu-
-;r motion, the binding of the molecule to other substancesor its
:dstence in a "free" state, and the size of the molecule. The
:rteraction among these three factors is complex. In general,T1
::laration is enhanced(shortened)by molecularmotion with mod-
.:ate speed, or by medium-sized molecules that are "partially"
:-.und. T1 relaxation is lengthened by very slow- or very fast-
:o\-ing molecules, and by larger, bound and smaller, unbound
::olecules. For example, water is a small, fast-moving molecule
of C omputedTomography
and Magneti cR esonance
lm aging 3l
Table 3-2. Representative Tl and T2 relaxation times
(in msecl of different parts within the body (as measured
with a GE Signa, 1.5 Tesla MR lmagerl3
Structure Tl value T2 value
White matter 589 msec 76 msec
Gray matter 1 2 1 5m s e c 1 0 6 m se c
C e r e b r o s p i n af l u i d 2000 msec 1 2 0 0m se c
Water 3000 msec >2000 msec
that is not bound ("free") and has a T1 relaxation of 3000 msec,
whereasprotein-bound water has a shorter T1 relaxation.
When an MR image is reviewed, structures are referred to by
the intensity of signal that is produced, with white being considered
"hyper"-intense, or with high signal intensity, and black being
considered"hypo"-intense, or with low signal strength or signal
void. On Tl-weighted images (see spin-echo imaging later), a
structure with a prolonged Tl relaxation(e.g.,cerebrospinalfluid)
will appear hypointense (black), whereas a structure with a short
Tl relaxation (e.g.,fat) will appearhyperintense(white).
Differences in intensity on a Tl-weighted image that influence
soft-tissue contrast include proton density and the differences in
Tl rela-xation rates between two tissues. Factors that influence
T1 relaxation include the strength of the magnetic field and the
paramagnetic contrast agents. Use of low-field-strength magnets
(0.5 Tesla)results in increasedsoft-tissuecontrast differencesbe-
10,11Intravenous para-
tween tissueswith different Tl rela-xations.3,
magnetic substances, such as gadopentetatedimeglumine (Magne-
vist), decreaseT1 relaxation times. The normal range of T1
relaxationtimes in the body is between 100 and 2500 msec. Some
representativeT1 relaxation times are shown in Table 3-2. T1-
weighted images can be obtained in a relatively short time (3 to 5
minutes) in any of the imaging planes. Tl-weighted images usually
best demonstrate the anatomy of a specific structure, particularly
the brain.
T2 relaxation (spin-spin or transverse
relaxation)
T2 relaxation is defined as the time recuired to reduce the net
transversemagnetization to 37o/oof its orlginal value. Therefore, a
short T2 means a rapid loss of transversemagnetization (after the
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
can interact in several ways. First, the energy is absorbed by the
lattice or environment and directlv impacts the thermal molecular
motions of the tissue.This procesi is risponsible for T1 relaxation.
Secondly,the energy releasedcould be absorbed by another proton
that is then shifted from low energy to a higher state of energy.T2
relaxation is basedupon direct proton-proton interactions, wherein
the released energy is absorbed by another proton. This energy
exchangeresults in changesin the spin orientation of the proton
and is therefore called spin-spin relaxation. The T2* is the actual
relaxation time that is initially measured (Fig. 3-a) because of
imperfections in the magnetic field that result in altered T2 relax-
ation characteristics.
In summary, T2 relaxation occurs after the net magnetization
vector has been rotated into the transverse plane. Now, the large
magnetization vector in the x-7 plane loses coherenceowing to the
local interference of the proton's own minute magnetic field and
the inherent inhomogeneities in the externally applied magnetic
field. The protons exchangetheir energy with neighboring protons
through interactions with their spin states.Protons that are found
in the fluid state have decreasedspin interactions with their neigh-
bors, and thereforelonger T2 relaxation times (msec).The range
of T2 relaxation times in various tissuesis between 20 and 2000
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
have a higher signal intensity (they appearwhite on T2-weighted
images). Additionally, increasing the field strength has little effect
on T2, and the T2 values are always less than the T1 values for a
given body tissue. The appearanceof different structures on T1-
and T2-weighted images is summarized in Table 3-3.
Physical basis of spin-echo imaging
Different pulse sequencesthat can be applied during MR imaging
of the patient emphasizesignal recorded from a particular type of
relaxation process. The combination of the characteristics and
specific timing of the radiofrequency pulses with the application of
the magnetic field gradientsis called a pulse sequence.The basic
pulse sequencecan be defined as the application of an excitation
pulse followed by a time of listening for the signal given off by the
tissues. In some sequences,rephasing pulses can be applied that
allow for ma-ximization of the initial excitation pulse becausethey
are able to "read" smaller signals, called echoes. Some of these
pulsed sequencesemphasizejust T1 relaxation (called saturation-
recovery and inversion-recovery). Some pulse sequencescan be
used to emphasizefluid in the vesselsor to de-emphasizefat in the
tissues. This latter technique is called fat saturation; it results in
black, or signal void, in areasof fat.
The most common pulse sequenceused today for routine MR
imaging is called spin-echoand fast spin-echoT2 imaging. In this
sequence,one can obtain two different image sets (Tl-weighted
images and T2-weighted images) of a tissue by altering the pulse
sequencewithin the spin-echo imaging protocol. Images reflecting
proton density can be obtained using standard spin_echo_t1pe
sequencesas well. Protocols for various imaging ,.qrr.rr.., urrd
specificdiseaseprocessesare continuouslybeing modihed and are
beyond the scope of this text.
As has been previously stated, the timing of an MR sequenceis
critical as to which relaxation characteristiis are emphasized.One
can think of these sequencesas a series of repetitive expertments
that are done to increasethe signal-to-noiseraiio. As one increases
the number of pulse sequences performed,the signal-to-noiseratio
increases.The number of excitations(or NEX) is the number of
pulse sequences that are done with the same x-,y-, and.z-gradients.
A pulse sequenceis made up of (1) an initial 90-degree-radiofre_
g".l:y pulse (along with an application of a z-gradient for slice
Iocalization),(2) application of a y-gradient,(3) ; rephasing180_
degreeradiofrequencypulse, and (4) an echo time for recordine of
the signal (along with application of an x- or readout gradiint;
Fig. 3-s).
As has been mentioned, these puise sequences are centered
around an initial excitation radiofrequency puise of the area or
slice that is being imaged. The initial fn signat is ignored in this
process, and a second radiofrequency pulse that .,rephases,'the
protons is applied so that a signal (echo) is created. The time
betweenthe application of the initial 90-degreepulse and the peak
of the echo signal is called the echo time, oi TE.-Th. TE is actuallv
the time when the signal induced in the receiver coiis is recordei
and is used for producing the MR image. Additional lS0-degree
pulses can be applied that will result irr smaller echoes from-the
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
g0' 180"
F i g u r e 3 - 5 . T h e sr a n d a r dp r lse se -
o u e n c e f o r s o i n - ech otwo - d im e n sio n a l
F o u r i etrr a n s f o r mm a g n e ticr e so n a n ce im -
a g i n g .T h e R F p u l se sa n d r e a d o u tsig n a ls
are displayedalongthe top line.The differ-
e n t e n c o d i n gg r a d i e n ts
a r ea p p lle din th r e e
differentdirectionsfor objector arealocal-
izationwithin the patient. Each of these
differentgradientstakes advantageof an
establishedgradientin the x, y, and z di-
r e c t i o n ss o t h a t s i g n a isfr o m th e vo lu m e
of data can be orientedcorrectlyin three-
d i m e n s i o n aslp a c ein th e fin a ld a tase t fo r
image reconstruction. RF,radiofrequency.
erponential curve can be fit to the peaks of the FID echoes,which
will give the true time constant that is equal to T2. In summary,
an initial 9O-degreepulse is used to rotate the proton magnetic
vector into the x-y plane. A series of l8O-degree radiofrequency
pulses are applied that result in multiple echoes,which can be used
for the creation of the MR image. The time between successive
applications of 90-degree pulses is called the repetition time, or
TR. The delay time, or TD represents the delay between the
recording of the final echo and the initiation of the next 90-degree
radiofrequency pulse.
By varying the TR and TE, one can emphasizeT1 relaxation, T2
relaxation, or proton density as the parameter creating signal in
the image. A short TR (400 msec) and a short TE (20 msec)
emphasizeT1 relaxation. A long TR and a long TE emphasizeT2
relaxation. A long TR (2000 msec) and a short TE (20 msec)
emphasizeprimarily proton density.
Image Iocalization is accomplished by altering the strength of
the static magnetic field along rhe x-, y-, and z-directions of the
magnetic field. Localization occurs because of specially designed
gradient coils in the bore of the magnet. These gradients are
applied during different times of the spin-echo pulse sequenceso
that the echo signal that is given off can be accurately localized to
a given voxel within the volume of tissue, or a given slice of tissue
being imaged. The z-gradient (also called the slice-selectgradient)
Figure 3-6. Transverse f1- A) and f2-
.',elghtedfB, pre-contrastmagnetic resonance
r : a g e s f r o m a n 8- ye a r - o ld ,m a le m in ia tu r e
a rceh s h u n dw i t h a la r g e r ig h t fo r e b r a inm a ss.
-- -r e i s a n a r e a o f h yp e r in r e n sityn o te d
: ^ r o u g h o u t h e t u mo r o n th e T 2 - we ig h te dim -
a g e . L e s i o nc h a r a cte r istics a r e co n siste nwitht
- g h w a t e r c o n t e n t. Histo lo g ica lly, th is le sio n
, ' , ' a sa g l r o m a .
of ComputedTomography
and MagneticResonancelmaging 33
90" 180" 900 190"
RF p ul s esand
echos i gnal s
.4- z- gr a di ent
\, Sliceselectgr adient
y- gr adi ent
Phaseencodegr adient
x- gr adi ent
is applied at the time ofthe 9O-degree and the 1B0-degree radiofre-
quency pulses. The y-gradient (phase-encodegradient) is applied
after the initial 9O-degreepulse and prior to the l8O-degreepulse.
The x-gradient (frequency-encodegradient) is applied at the time
of the echo, so it is also called the readout gradient. Protons precess
at different frequencies owing to differences in the local magnetic
field strength (Bo); different signal frequenciesresult, based on the
Larmor equation. The frequency of these signals can be localized
to the known proton. The signal strength gives rise to the intensity
of the gray scalevalue that will be assignedto that given voxel.
Two-dimensional and three-dimensional imaging modalities are
available in most MR scannerstoday. In two-dimensional imaging,
specific transverseslices are excited (usually 2-3 slices at a time),
and somewhat like a CT scanner, the data are acquired slice by
slice. In three-dimensionai imaging, a volume of information is
obtained that can then be reformatted into any anatomic or oblique
plane desired.
Image contrast is dependent on the spin-echo pulse sequence
selectedand the relaxation properties of the tissue in question. In
general, the effects of Tl and T2 changes are opposite. In T1-
weighted images when peritumoral edema is present, there is a
hypointense signal, whereas in a T2-weighted image, the peritu-
moral edema will appear hyperintense (Figs. 3-6 and 3-7). Para-
magnetic contrast agentsdecreaseboth T1 andT2, which increases
34 P HY S I CS
A ND PR IN C IPL EOF
S IN T E R P R E TA TION

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

C. The time required to reduce the net longitudinal magnetiza- D. Methemoglobin.

tion to 630/oof its original value. E. Cerebrospinalfluid.
D. The time required to increasethe net longitudinal magneti-
zation to 630/oof its original value. 9. A1l of the foliowing will enhance or shorten T1 relaxation
Irmes, excepf,
8. A structure within the brain that is hypointense(black) on T1- A. Fast-movingmolecules.
weighted images and hyperintense (white) on T2-weighted images B. Medium-sizedmolecules.
is most likely: C. Partially bound molecules.
A. Gray matter. D. Medium-speedmolecules.
B. \4/hite matter.
C. The red nucleus. Answers begin on page 727.

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

Figure tI-2. lt is very difficultto alignpartiallycoveredlines.Again,using a

Figure zl-1. Which ine is longer?Actual measurementsmay surpriseyou rul eror a st"ai ghT
paperedge may S U rp'i se
V oL.
36 P HY S I CS O F IN T E R P R E TA TION
A ND P R IN C IP L ES

@Y 393
@

@6 Figure 4-3. Which nodule (stippledcenter) is bigger?The backgroundinfluences

size percepton.

Figure tl4. Apparentcardiomegaly obtainedduringexpiration

on radiographs
ts a very common perceptualerror.

Figure zl-5. Mach lines (Mach phenomenon)are persistentoptrcalillusionsthat are

producedby a l aterali nhi bl ti onneuralnetw orkw i th n the reti na.They appearas fal s e
w hi te or bl ackl i nesat sharpboundari es.Thi s i l l usl onenhancesbounda rydetec ti onbut
can mi mi c l esi ons(fractures)
or anatomi cstructures(bow elw al l , bl adderw aLl ).

-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

: (no changein brightness).Such subjectivecontours are the resrilt

:: of mental completion of partial lines to form familiar (expected)
). shapes.r3-IsHere is one example:When viewing three dots, most
j

).
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.

I The theory of percepts

Figure 4-6. The eye rs a poor judge of absolutebrightness,as convincingly
il ustratedby the contrastbackgroundeffect. All of the sma I centra squares
n t h i s i l l u s t r a t r oanre o f id e n ticabi n g h tn e ss.
T h e co n tr a stb ackground
effecti s
a c o m b i n a t i oonf t h e M a ch p h e n o m e n o a n n d su b je ctiveco ntours.
I Subjective contours
Radiographs are two-dimensional images, depicting exclusivelythe
contour of objects. They are images of shadows.Unlike the familiar
shadows that surround us, however, radiographs are a summation
of multiple types of shadows.This added complexity gives the false
impression that the images are more than a collection of shadows,
which leads to numerous perceptual errors. One should never
forget that radiographs are merely images of shadows, and that
shadowsdepict only the contour of objects(Ftg. a-7).
Contours are perceived when there is an abrupt change in the
luminance or color of adjacentareas.IUnder certain circumstances,
It is widely accepted that visual signals do not produce integral
images in our brain: Transmission and reconstruction of integral
visual information would require too much "computing" power.
Visual signals appear to be compared with mental images stored in
memory. A meaningful image is perceivedonly when visual signals,
after multiple comparisons, induce the emergenceof a compatible
mental image in our brain/mind (Fig. 4-10). The mental images,
called percepts,are continuously modified by experience.r, e'14
Therefore,what we "see" is a mental image (percept) brought to
consciousness and touched up by visual signals(shape,size,color,
distance,motion, etc.). This theory explains the vivid images "seen"
during dreams and hallucinations: They are percepts emerging
spontaneously without control from visual signals. One could say
that the purpose of our sensesduring waking hours is to induce a
"dream" (series of percepts) and to make it as compatible as
possiblewith physicalreality.
Figure 4-11 is an example of a waking "dream" adrift. The
objective visual information is limited to three black patches. each
with a triangular defect. When viewing this figure, however, most
of us perceive a large white triangle partially covering three black
patches.Where is the white triangle coming from? The triangle has
no physical reality other than in our brain/mind. When the visual
signals are compared with memorized mental images (percepts),
our perceptionmechanismsconclude,basedon our previous expe-
rience in the three-dimensional world, that the most likely explana-
tion for the visual signals is the following percept: a white triangle
partially covering three black patches. And the image emerges in
consciousness.r' i4 The problem is that the "dream" is
based as
much (or more) on previous experienceas on physical reality. For
some of us, the illusion (mental image) is so strong that the

Figure tl-7. The examrnattonof familiarobjects reminds

u s t h a t r a d r o g r a p hs
a r e im a g e so f sh a d o wsth a t sh o w o n ly
conlours.
38 P HY S I CS S IN T ER PR ET A TION
A ND P R IN C IPL EOF
o a
aa
aa
Figure tt-8, Sevenb/ackdots are perceivedas a triangleand a square
triangle may appear lighter than the background, creating definite
bordlrs between the patches, even though the retinal stimulation
is the same in both rigions' Would you perceive a triangle if-you
had never seen one or assimilated the concept before? Based on
the experienceof people who were blind at birth but "cured" later'
the answer is "certainly not."l Would you perceivea megaesophagus
on radiographs if you had never seenone with your mind's eye be-
fore?
When the brain/mind has already been sensitizedand expectsa
percept, limited information-or even unrelated information-can
induce the mental image (Fig. a-I2). This phenomenon explains
many radiographic errors, as well as some hunting accidents!
If'the number of visual signals supporting the mentai image
increases,compatibility with the percept builds and the perception
becomesstronger and more stable (Fig. 4-13). The opposite phe-
nomenon o...r.. u. well, that is' when the brainimind does not
expect or desire a certain discovery,sufficient information may not
iniuce the perception. Everyone should be able to find a few
examplesof this phenomenon in personalexperience'
On radiographs, subjective contours often appear as abdominal
massesor falsJkidneys createdby neighboring bowel loops, or as
cavitarylesions in the lungs produced by adjacent areasofincreased
opacity (Figs. 4-14 and 4-15)' Superimposition of pulmonary
biood vesseli and ribs regularly mimics pulmonary nodules, partic-
ularly when blurred by motion or pulmonary opacification'l3 A-l-
though it is very persistent,a subjectivecontour is not an irrevers-
ible iilusion; close examination of the radiograph often revealsthat
the contour is produced by unrelated opacities.Our desire-or
lack of desire--to find a iesion should never prevent us from
performing a close examination of the contour every time an
abnormality is "seen."
I Multistability of PercePtions
Multistability of perception is another phenomenon that illustrates
the fundamental difference between vision and perception' Figures
4-16 and.4-17 provide classic examples. Such figures are called
ambiguous, or reversible, becausethey represent images that may
be perceivedin different ways.''''16 If you look at Figure 4-16, you
wili most likely perceivea translucent cube seenfrom above' If you
stare at it long enough, however, a similar but different cube
appears)seenfrom below. Once both perceptionshave been trig-
Figure /t-9, The same dots could as well be parts of a circle and a com-
plexf i g u r e .
O
Otherinputs
Percept Percept Percept Percept Percept
+
Perceived image
Figurc 4-1O. An imageis percelved inducethe
onlywhenvisualsignals
emergerceot a pe'cepti^ ourbrain/and.
gered, they alternate as if two different images were rapidly inter-
changed. Most of us perceive the "cube from above" first because
based on our experience,it is more likely to find a cube resting on
a surface than one floating weightlessly in midair. Note that only
one perception is "seen" at any moment; the apparition of one
forces the other out. Can you seethe second image in Figue 4-172.
It may help to turn the page upside down. Figure 4-18 is another
example of different mental images triggered by the same visual
signals.If one had never seen a seagull,the only image perceived
would be that of a rabbit, and vice versa. If both animals are
familiar to the observer,the perceptions alternate. Here again, note
that both animals are never "seen" at the same time; the emergence
of percepts appearsto be an all-or-nothing phenomenon. Brain
mapping experiments suggest that perceptions arise from large-
scale quantum changes in the collective activity of millions of
neurons.lTFigure 4-19 illustratesperceptualerrors causedby the
gradual progressionfrom one stateto another (e.g.,from normal
to pathologic in medicine). Becauseperceptsappear to be an all-
or-nothing phenomenon,we have a strong tendencyto seethings
either one way or another (good or bad, masculine or feminine
fsee Fig. 4-19], normal or abnormal, etc.), even if we know that
the criteria usedto supPortthe conclusionspreadinto a continuous
range. In the midsection of the spectrum-a frequent occurrence
in radiology-it is easy to understand how preconceptions have a
definite effect on the percept triggered by the visual signals'
\ rhat do we learn from those disconcerting flgures? We learn
that two observers looking at the same radiograph, or the same
observer looking at one radiograph at two different times, may
have different perceptions.The plurality of perception has been
suggestedas the major explanation for the interobserver and in-
traobservererror rate of 20o/oro 30o/oin radiology.lo'
r'?'r8 If this
hypothesis is true, multiple readings may be the only way to reduce
inconsistencvof interpretation.i0
Figure 4-11, The visual lnformationis limitedto three b/ackpatcheswlth
small trlangulardefects.Where ts the /argewhite trianglecomingfrom?
G

_/
Figure zl-12. When the brain/mindhas been sensitizedor expects the
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.
I Knowledge, emotions, and
I perception
Knowledge and emotions change continually, and both influence
perception. We see more easily what is set or expectedto be seen,
and we are less likely to see what has no apparent connection
with-or contradicts-the idea we have in mind when we examine
ambiguous medical images. This influence is unavoidable because
perception is not the exact copying of an incoming stimulus: It is
a fusion of sensory signals with past experience and expectations
that allows simultaneous identification of the stimulus and its
significance." The plurality of perception is particularly apparent
when radiologists have to make a diagnosis under conditions of
uncertainty,I2 and this is not an uncommon situation. Interpreta-
tion of radiographs for evidence of progression,regression,or
stability of diseaseis also grosslyinconsistent.r0 The consequences
are seriousbecausemany clinical decisionsare based on the pro-
gression of lesions seen on serial radiographs.In such circum-
stances,the observer'sattitude has a definite effect on radiographic
interpretation. A pessimisticattitude, createdfor example by having
missedpulmonary metastases in a previous patient, would make a
ciinician more likely to call an ill-defined shadow a nodule. Such
an attitude would increasethe number of true lesionsdetected,but
at the same time would increase the number of false-positive
diagnoses.i'? On the other hand, a more optimistic attitude would
decreasethe number of true-positivelesions,but would decrease
the number of false-negativediagnoses.Thus attitude affectsinter-
pretation, but what is the right one to adopt? The ideal attitude
should be determined by the number of false-positivediagnoses
one is willing to accept.12The decisionshould alsobe basedon the
clinical significanceof a positive finding, as well as on the reliability
and invasivenessof other tests likely to be used to confirm or rule
out the radiographic diagnosis. Even when they have the best
])r
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
VisualPerceptionand Radiographic
lnterpretation 39
b?
Figure tI-14. False kdneys or abdominalmasses can be "created'
unrelatedloopsof bowe .
intentions, however, it is apparently impossible for human beings
to maintain a constant attitude over a long period.
Visual perception and
I
I radiology teaching
The theory of percepts should be consideredin the design of
radiology teaching.leTo trained radiologists,integration of radio-
graphic information is easy,automatic, and often taken for granted.
The distress of students as they struggle to learn to "see" is a
reminder of the complexity of image perception.For students,the
radiology world is a hodgepodge from which they occasionally
glean a useful bit of information. Perception occurs only after
comparison is made between visual signals and memorized per-
cepts. Because neophytes are faced with foreign visual signals,
radiographsremain a confusingjumble of unconnectedshadesof
gray until their brain/mind has fully integrated into a unified
explanation the separatevisual cues of opacity, size,shape,location,
and distortions associatedwith shadows. Such intesration should
be slowly developed with radiographic images of fimiliar objects
becauseimages cannot be interpreted without previous exposure
to, and assimilation of, the objects or concepts represented.', 1e
Only when this work with familiar objects has been done should
tissuesand pathologic processesbe introduced; it should alwaysbe
kept in mind that previous assimilation of the anatomic and patho-
logic conceptsrepresentedis necessaryfor perceptionsto occur.
One needs to know what to expect before "seeing" occurs. It takes
yearsto become expert at interpreting our three-dimensional visual
world. It also takes years to become expert at discovering the
meaning of two-dimensional images of shadows that show the
distribution and concentrationof electronsin patients.
I Visual search
We all know that radiographs should be searchedthoroughly, but
how complete is a "complete" search? Studies have shown that
large areas of radiographs are unexplored, even when interpreted
by experiencedradiologists.'?O
" For the most part, this is not the
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
FiguretI-I6. Thisimagecantriggerthe perception
of two differentcubes.
result of carelessness;it is the consequence of complex visual
mechanisms,many of which are not under consciouscontrol.2.
The area of acutevision is a lot smallerthan most of us recognize.
The fovea, the small area at the center of the retina, which is
densely packed with visual receptors, is the only structure of the
eye that is capable of detailed vision. During interpretation of an
image, eye movements temporarily fix the fovea on different parts
of the image while the indistinct information gathered by the
peripheral vision is used to trigger subjective contours and other
percepts, as well as to guide eye movements via oculomotor re-
flexes.'OA radiographic abnormality is easier to detect if it stands
out from the background (high contrast) becauseit is more likely
to be detected by the peripheral vision and to attract visual atten-
tion (Figs. 4-20 and 4-21). Our eyesalmost constantly move from
fixation to fixation in a successionof jumps. Each fixation lasts
about one third of a second.Becausevision is blurred during eye
movement, we effectively see only when the eye is still, which can
be as little as 30oloof the time.2o'2rWe are unaware of this saccadic
input of information becausethe process is very efficiently
smoothed in the visual perception centers. This smoothing of the
visual input along with the filling of the peripheral field by mental
images is dangerous in radiology becauseone has the impression
of seeing in detail a large area at one giance, when the actual area
of acute vision is only about the size of a dime at a distance of 60
cm,t''('
The apparentiy simple act of reading text displays the effective-
ness and complexity of the filling mechanisms. An experienced
Figure 4-17. lt is so unusualto see stairwaysupsidedown that you may
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-
N ESS.
Figuretl-I8, Differentpercepts
triggered
by thesameimage.lf rabbits
and
seagulls
arefamiliar theperceptions
to theobserver, a ternate.
Notethatboth
arenever"seen"at thesametime.
reader makes three or four jumps per line (this is probably what
you are doing at this moment). Even if you actually see in detail
only 6 to 12 charactersper 1ine,you have the impression of having
seenthem all clearly. Fix your eyeson any word on this page for a
few seconds.Most of the page will turn into a blur and you will
see clearly only two or three letters. This very small surface of the
page is the only one that is actually seen in detail at any given
time. You might be able to identifr one or two short words on
either side of the fixation, but note how this identification is
based more on extrapolation from word iength and grammatical
construction than on seeing the actual letters. \A{hen you resume
reading, you have the impression of seeing every letter of every
word again.The smoothing procedureis done by our brain/mind,
which fills in the missing information using our knowledge of the
English language (as the triangle in Figure 4-7 is filled in, using
our knowledge of triangles). The faster we read, the longer the
jumps, and the more information is filled in by the mind. This is
why we have such difficulty finding typos, particularly in a familiar
text. Reading a text written in a foreign language makes one
appreciate the effect of previous knowledge on perception: "De
toute evidence, lire cette courte phrase en francais vous prendra
beaucoup pius de temps que si elle avait ete ecrite en anglais."
The same phenomenon occurs with radiographs: The more
familiar we are with the images, the more comfortable we become
and the faster we can discover their meaning, but at the same time,
the more information is filled in by the mind. Another interesting
aspectof eye jumps is that their dynamics are not under conscious
control; we cannot changethe length or direction of a jump once
it is initiated. Therefore, we cannot be certain about what we
R
ri l r(\
/r\ll
(-\
Figure tI-I9. Progressivefigures show how preconceptionscan infuence
percepti on,parti cul arli yn condi ti onsof uncertai nty
or i f the phe nomenonob'
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.

.- 'r.t. t t.'.i.-.' I Gonclusion

..;'.f
a_-
i!.:t
a r O '.
tt
.r tt- ' .
Fisure/t-zo. *r'".. .n.i*-o
tectedby the peripheral
vision.Howmanylargerdotsdo youfind?
actually see and what is filled in.'o'" The best we can do to control
a search pattern is to concentrate on a certain area; the details of
the searchare always left to an unconscious part of our visual sys-
tem.2o
Still skeptical?Tiy to find how many times the letter "F" is used
in Figure 4-22 withort reading any further. Most of us find four
or five. The answer is seven. If you cannot find them all after
severalattempts, try reading backward (which suppressesthe "fill-
in" mechanisms). Do you still believe you have full control over
your eye jumps?
Knowing that we see in detail a surface that is only the size of a
dime, that it is impossible to accurately control where the "dime"
will rest on the image, that we see only one third of the time we
are actually "lookingi' and that it is impossible to know how much
we actually seeand how much information our brain/mind filis in,
makes it easierfor us to understand how psychologicalfactors such
as interest, motivation, training, and emotions can modifr the way
we search, perceive, and interpret radiographs-as well as how
lesionscan be missed.
A systematicapproach is important for interpreting radiographs
to counterbalancethe shortcomings of our visual system.
atrlt-a..-qa
t- .1.
lt at t r ' This review may give the impression that radiology is less reliable
than other fields of medicine, but a similar error rate has been
;t.lo,i-', ,^" backsround
areeasily
de- found regarding the ability to detect and describe lesions such as
heart murmurs.t0 It appears that several aspectsof medicine may
be subject to a significant error rate that is rooted in the difference
between sensory detection and perception.lo Familiarity with per-
ceptual mechanisms and with the limitations of our sensesmay be
the only way to reduce perceptual errors. However, rational knowl-
edge does not correct all perceptual errors, and they will remain a
major challengein radiology as well as in other fields of medicine.
If you remain unconvinced, gather 25 radiographs for which you
have generated reports, and write new reports without looking at
the previous ones. You will see things you did not seebefore, and
you will not see others that you saw then. These inconsistencies
are due to changesin subjective contours, multistability of percep-
tion, and visual searchprompted by differencesin patient informa-
tion (the good old retrospectoscope), pressurefrom the owner or
other clinicians, other stressesinfluencing concentration, or simply
the desire to prove that inconsistency of interpretation happens
only to others.
References
1. Wandell BA: Foundations ofVision. Sunderland, Sinauer Associates,1995.
2. Hebb DO, Favreau O: The mechanism of perception. Radiol Clin North Am
8:J ,196q.
3. Ravindra H, Normann RA, Baxter B: The effect of extraneous lieht on lesion
detectability: A demonstration. Invest Radiol 18:105-106, 1983.

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.

5. Baxter B, Ravindra H, Normann RA: Changes in lesion detectability caused by

-tt.'
t t' -t" ""illt light adaptation in retinal photoreceptors. Invest Radiol 17:394401, 1982.
^
. .to:'i.'.
"'! i,'ri i-..'.-irl.l'...
o r a r .r .- i- .- .' j!.
6. laffe CC: Medical Imaging, Vision, and Visual psychophysics. Rochester, Ny,
Eastman Kodak, 1984.
o^r ^
,.'.''.' :i:.:. i t^.'. . 3 .'-' .'. 7. PapageorgesM, Sande RD: The Mach phenomenon. Vet Radiol Ultrasound
. t: . . i- .- .- .
.^ ...- ' , ..t.t .
r :' - t...' 31:274 280,199O.
. ..-. ..
:tl- .
. ..o .i.-'...-. ! j. ..i.-.. .' 8. PapageorgesM; How the Mach phenomenon and shape affect the radiographic
t^ a o I a ta-a t a aa a o o .l
r. t^ :-o r... .....r1.. : i....., |' i......
o a . a a .
appearanceof skeletal structures. Vet Radiol 32:19I-195, \99I.
t' -.
'
larato ' .' .l:i.-t.1Jj.....'.lJj,j.. .
" aaaa,a
9. Zeki S: The visuai image. In Piel J (ed): Mind and Brain. New york, Scientific
Amencan, 1992, pp 69-76.
r I ro tr. -r:.::..\',,ri3l ".,. i..i;'
tt-a tt 10. Yerushalmy J: The statistical assessmentof the variability in observer perception
" aaa- ]a- t.... and description of roentgenographic pulmonary shadows. Radiol Clin North Am
t^a ta t'a -a' . ' a.at- r Jr ta
-t a aoo - ao r
t.'.f .,'.1. t t . :.^. - a- -
.
8:101- 108,1969.
|: ::
" Ot e . a la-a-a t -t l.-.
o r I l. Markus JB, Somers S, Slobodan EF, et al: Interobserver variation in the interpreta-

'
' .'. ! :..'.: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'
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
of coal workers' pneumoconiosis.Br .l Ind Med 8:138, 1954.
19. Squire LF: Perception related to learning radiology in medical school Radiol Clin
North Am 7:485-497, 1969.
20. Llewellp Thomas E: Search behavior. Radiol Clin North Am 8:138' 1969'
21. Llewellyn-Thomas E, Lansdowne EL: Visual search patterns of radiologists in
training. Radiology 811288-292,1963.
22. Tuddenhan Wl, Calvert WF: Visual search patterns in roentgen diagnosis. Radiol-
ogy 76:694-704, 1961.
23. Kundel HL, LaFollette PS: Visual search patterns and experience with radiological
images. Radiology 103:523 528, 1972.

aL-.tn PTER

5
lntroduction to Radiographic
lnterpretation
. Clifford R. Berry I Nancl E. Love ' Donald E. Thrall

I X-rays and radiographs passthrough unchanged,thus producing film blackening(seeFig'

5-1). Of particular importance is the fact that x-rays are not
The science of radiology is based on the ability of x-rays to
penetratematter.When a patient is struck by an x-ray beam, some absorbed homogeneously by the body. This phenomenon is called
i-ruy, u.. absorbed,some ure scattered,and others passthrough dffirential absorption.If absorption of x-rays by the patient were
unchanged.A radiograph is an image of the number and distribu- uniform (no differential absorption), the resulting radiographic
tion oithe ihal pass through the patient and strike the image would be homogeneouslygray or white. If no absorption
"-rays occurred,the resultingradiographwould be homogeneouslyblack.
cassette.largon terms such as x-ray, lilm, plate, and picture arc
sometimesused as names for a radiograph, but this is incorrect The effect of differential absorption is illustrated in Figure 5-2' in
and should be avoided. which the areasbetween the fingers and adjacent to the hand are
The blacknessof a radiograph is dependenton the number of black becauseno x-rays from the incident or primary x-ray beam
x-rays absorbed by the intensifying screen,and thus the amount ot were absorbed before reaching the intensifuing screen. Soft tissues
lighi exposingthe radiographicfilm. Areas struck by a large num-
bir of i-ravJ are black (radiolucent) after fi1m processing.Con-
versely, areasstruck by few x-rays are translucent or appear white
(radiopaque).Betweenthese two extremesis a range of gray film-
X-RAY BEAM
-the rl
iones, blacknessof which is directly related to the number of
x-rays that reach the film or the intensifring screen (Figs' 5-1
ana )-z).
The deqree of blackening of the film is measured in terms of
ll ti
optical dJnsity. Optical de-nsity and film blackness are directly
related (Fig. S-:). the rerm densityis sometimesused to describe
the degreelo which a patient or object absorbsincident x-rays' For
."u*pI., in Figure 5-2, some would say that the ring, -watch, and
bonei are d.tt.e than adjacentsoft tissue.Use of density in
this context is confusing becausethe optical density of the fi1m in
-ot-"
these areas is low whireas the object density is high. Further
confusion arises when the added variable of physical density (g/
cm') of the patient or object is considered.As the physicaldensity
of the patient or object increases,the optical film density decreases
and thi object or radiographic density increases.'Thisconfusing
terminology can be eliminated by avoiding use of rhe rerm density l
to describ-e'radiographic changes(Fig. 5-a). The degreeof black-- FILM
nessor whitenessof the patient should be referred to in terms of BLACKNESS
radiolucencyor radiopacity'For example,in Figure 5-2, soft tissues SCALE
of the hand are less radiopaque than the bones; both are more
radiolucent than the watch and the ring. It may also be said that Figure 5-1. Diagramillustrating the princrpe of the effect of tlssuecompos-
the watch and the ring are more radiopaque than the remainder tion on the absorptlonof x-rays.A beam of x-rays strikes a large object
of the hand. DescribingradiographicaPpearance in terms of radio- containingthree regionsof higherphysicaldensityillustratedbYlhe two ctrcles
graphic opacity (air, fat, water, bone, and metal) eliminates the and the e//i pse.B eneaththe obj ecti s a scae of fi l m bl acknessW . herethe x -
ray beam does not hi t one of the smal l erobj ects,f l m bl ackn es w s i l l be the
Ioniusion-associatedwith use of the word density for such pur- greatest.B eneaththe smal l erobj ects,fi l m bl ackness w i l l be l e s s bec aus eof
poses. the absorpti on of x-raysby these obj ects.The degreeto w hi chfi l m bl ac k nes s
w l l be l essi s, n thi s exampl e,onl y a functi onof the thl cknesso f the s mal l er
I lmage formation and obi ects,becausethev are al l homogeneous and of the same phy s i c aldens i ty
fhe smal l ci rcl e on the ri ght affects fi l m bl acknessonl y minl mal l yw , hi l e
I differential absorption beneaththe elltpse,Itlm blacknessls decreasedconslderably. This decreased
It is possibleto use x-rays to produce an image of a patient on film blacknessresultsfrom the absorptionof more x rays in the thickerellipse,
film becausesome x-rays are absorbed by the patient, and some thus reduci ngthe numberof x-raysthat reachthe fi m.
 lntroductionto Radiographic
Interpretation43

t t i i
AIR FAT WATER BONE METAL

BADIOPACITY

RADIOLUCENCY

OPTICALDENSITY

FILM BLACKNESS

FADIOGRAPHICDENSITY

Figure 54. Theidentical thicknesses of five substances arestruckby an

equalnumberof x+ays.Not all substances absorbx+ayswith the same
efficiency.
Inthisexample, asthephysical densityandeffective aromtcnumDer
increase (fromleft to right),the numberof x+ayspassingthroughthe sub-
stancedecreases. Thisdependency of differential
absorption basedon a mate-
rial'sphysicaldensityandatomc number is whatallowsx-rays to be useful
for
producing radiographs.As the numberof x+ayspassing through the object
changes, the blackness of the radiograph alsochanges. Notethe changes in
radiopacity thatoccurwith eachobjectabove.Useof the term "radiographic
density"is notrecommended butis inc{uded in thisfigurefor comparison.

Figure 5-2. Radiograph of a humanhand.Blackregionsrepresentfilm areas
where no x-rays were absorbedfrom the x ray beam before reachingthe
intensifyingscreens.Homogeneouslywhite areas,such as the watch and ring,
are film areaswhere essentiallya// x-rayswere absorbedfrom the incidentx-
ray beam prior to interactionof the x-rayswith the intensifyingscreen. Be-
tween these two extremes are many shades of gray resultingfrom various
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
obviousthat the bones absorbedmore x-rays(andare thus more radiopaque)
th a n d i d t h e f l e s h voa r tso f th e h a n d .
of the hand are visible because they have absorbed some x-rays
from the primary beam. Bones of the hand are more radiopaque
than soft tissues;the bones have absorbed more x-rays, and thus
that part of the intensi$ring screen under the bones was struck by
fewer x-rays than the part under the fleshy parts of the hand. The
watch and ring appear totally radiopaque becauseessentiallyno x-
rays were able to pass through them. The degree of differential
absorption of x-rays by a patient or an object depends on the
energy of the x-rays and the composition of the patient or object,
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

The next most radiopaque substance in Table 5-1 is fat. A1-

though the effective atomic number of fat is less than that of air,
its physical density is greater, making fat more radiopaque than
air. Next, consider the physical density and effectiveatomic number
of water and muscle. It may be theorized that muscle would be
more radiopaquethan water becauseof its higher physicaldensity
and effective atomic number. However, the radiographic imaging
system is not sensitiveenough to allow discrimination between the
radiopacity of substanceswith such small differences in physical
densiiy and effective atomic number. Thus, the radiopacity of
most fluids (e.g., b1ood, urine, transudates,exudates,bile, and
cerebrospinalfluid) and nonmineraiized' nonadiposetissues(e.g',
cartilage,muscle, fascia,tendons, ligaments,and parenchymalor-

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

Figure 5-5. Lateralview of abdomenln which the flve d fferent radiopacities

are re p r e s e n t e dA. i r : g a s i n th e b o we l.F a t: a d ip o setissu e n th e retroperl to-
nea sp a c e .F a t i s m o r e ra d io p a q u th e a n g a s, b u t e ss r a d lo p a que than tne
k idne y sS. o f t t i s s u e :t h e k id n e ys.No teth e su m m a tio nsh a d o wcr eatedby tne
ov erl a p p i nogf t h e c a u d a lp o le o f th e r ig h t kd n e y a n d th e cr a n ial e of the
pol Figure 5-7. Bone has greaterinherentradiopacitythan does fat (see Flgs.
left kidney(arrows).Bone: the vertebrae.Metal: the shotgun pe let The exact 5-4 and 5-5). H ow ever,i nherentradi opaci tl es are rel ati veto th tc k nes sand
,
loc at i o no f t h e p e L l e ct a n n o tb e d e te r m in e dfr o m th s la te r a view l al one.l t th cknesscancausesubstances w i th hi gheri nherentradi opaci tyto appearl es s
space,or
a l a ce ,o r th e r e tr o p e r lto neal
c oud b e r n t h e s k i n ,t h e i ntr a p e r ito n esp opaque.In thi s exampl e,100 x-rayshi t a thi n pi eceof bone and a thi c k pi ec e
it c oud b e l y i n go n t o p o f th e x r a y ta be , u n d e rth e d o g T wo view s, at 90 of fat. More x-raysare absorbedin the fat becauseof its greaterthickness,
degre e st o e a c h o t h e r ,a re n e ce ssa r yfo r id e n tlfyin gth e p r e cisel ocati ono{ the fat w l l actual l yappearmore opaquethan
and i n the resul ti ngradi ograph
anv oo l e c r . boneeventhoughi ts nherentradi opaci ty i s ess.
 Introduction
to Radiographic
Interpretation45

magnification and distortion, (2) image of a familiar part appearing

unfamiliar, (3) loss of depth perception, and (4) presenceof sum-
mation shadows.

Magnification and distortion

MagniJication refers to the enlargement of the image relative to its
actual size. Magnification varies with the object-film distance and
the focal spot-film distance. In clinical practice, object-film dis-
tance affectsmagnification more than focal spot-film distance does
becausefocal spot*film distance is tlpicaily constant. When object-
fi1m distance increases,magnification increases.In the magnified
image, each bit of visual information is spread over a larger area
of the film, which makes the image less sharp. It must be appreci-
ated that some parts of the patient are aiwaysfarther from the film
than other parts (Fig. 5-8). Thus, whenever possible, the area of
primary interest should be placed closest to the cassetteto avoid
magnification. The only exception to this rule is in radiography of
the small animal thorax whereby lesions in the dependent lung are
commonly not visualized becausethey silhouette (see later discus-
sion of silhouette sign) with the atelectaticdependent lung.
Distortion occurs when the image misrepresentsthe true shape
or position of the object. Distortion results from unequal magnifi-
cation of different parts of the same object; it can be minimized
by keeping the object and film planes parallel. Some distortion
occurs in every radiograph because there are always parts of the
patient that are not parallel to the film plane. Severe distortion,
however, may limit the diagnostic quality of the radiograph (Fig.
s-e).
Un familia r im age
An unfamiliar image of a familiar object sometimes results in Figure 5-9. Ventrodorsalview of the pelvis. The right femur was held
the object not being identifiable (Fig. 5-10). Therefore, patient paral l el
to tabl etop;the l eftfemurw as posrti oned w i th the sti fl es l i ghtl yfl ex ed.
Thi sresul tsi n the l eftfemurbei ngangl edrn rel ati onto the pri maryx -raybeam.
positioning for radiography must be standardized. Clinicians be- Thus, the l eft femur appearsshorterthan the ri ght and i s as y mmetri c al l y
come familiar with the radiographic appearanceof patients as a magni fi edbecauseof di storti on, that i s, i t w as not struc kperpendi c ul arlby y
result of positioning them in standard fashions. the x-raybeam.The l eft thi gh al so appearsmore radi op aque than the ri ght
becausethe thi cknessof ti ssuetraversedby the x+ay be am w as greateron
the l e't ow i ngro the l eg angul ari o^.
Loss of depth perception
Depth perceptiorzis lost in radiographs. To evaluate depth radio-
graphically, it is necessaryto make two radiographs of the object,
with one view at a 9O-degreeangle to the other. Depth can then be mentally reconstructed (see Fig. 5-5). In addition, some lesions
are apparent in only one radiographic projection (Fig. 5-11). Thus,
for each patient, a minimum of two views at 90 degrees from each
other, called orthogonal projections, should be obtained.

;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).

Silhouette sign (bordel effacement) is radiographed in sternal recunbency (dorsoventral radiograph)

The silhouette principle is based on the fact that when two struc-
tures of the same radiopacity are in contact, their margin cannot
be distinguished. Another term for this phenomenon is "border
effacement." Conversely,if two structures of the same radiopacity
are not in contact and are separatedby a substanceof a differing
radiopacity, their borders can be distinguished radiographically.
For example, consider Figure 5-14. The drawing represents a
thoracic cavity containing the heart, a lung, a coronary artery, and
pulmonary arteries.When radiographed, the coronary artery is not
visible becauseit is of the same radigraphic opacity as the heart,
and there is no intervening tissue of a different radiographic opac-
ity. The pulmonary arteries are visible, however, because even
though they are ofthe same radiographic opacity as the heart, they
do not touch the heart, and there is an intervening tissue (lung)
of another opacity (gas).
The silhouette sign often results in diseasesmasking normal
radiographic structures. For example, in patients with pleural effu-
sion, the pooling of fluid around the heart when the patient
rendersthe heart margin invisible (seeFig. 31-10). Another exam-
ple is noted in patients with peritoneal fluid because there are
diminished organ and bowel serosalmargins.
I lmportance of a contrasting
I substance
fust as the lack of a contrasting material prevents distinction
between two structures of the same opacity, the presence of a
contrasting material allows some structures to become exquisitely
visible in radiographs. This is particularly true when the con-
trasting material is air and the object in question is on the surface
of the body. For example,in many patients, nipples and the prepuce
are clearly visible in ventrodorsal radiographs of the body. These
structures are not particularly large, but they cast a disproportion-
ately opaque shadow becausethey are surrounded by air and their
margins are parallel to the central x-ray beam, thus providing
optimal geometry for visualization(Fig. 5-15).

Figure 5-11. Lareral(A)and ventrodorsal/B/ radiographsof a caninelumbar

soine. A. There is a displacedfracture of L7. B, fhe fracture itself cannot be
. m el esi onsare moreapparent
d le n g th So
s e e n ;h o w e ve rL, 7 a p p e a r sd e cr e a se in
on one radiographlcprojectlonthan on others. Thus, at least two orthogonal
projectionsof a body part shouldbe made routinely.
 .- 5l /On
-e -6 b 6 ^ I t,n1 Introducti on
to R adi ographiInt
c er pr et at ion47

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.

Figure5-16. Perceptlon artfact.Thetwo vertical
linesappear
curved.Place
a rulernextto them,andyouwillseetheyarestraight. Thisoptical
ilusionis
createdby the radrating
lineson whlchlhe curvedlinesare supermposed.
Perceptioncanbea source of errorin assessing
radiographic
abnorma ities.
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.
This approach, however, assumesthat one knows how to assess
the entire radiograph, and not just a particular section of the
radiograph such as the pleural space.Additionally, the division of
material within this textbook into chapters based on regional anat-
omy does not facilitate the collective approach needed for evalua-
tion of a radiographic study. Finally, it is impossible in any book
to illustrate all of the radiographic variations of an abnormality.
The reality is that we will be faced with a spectrum of radiographic
appearancesfor a given diseasecategory. For example, panosteitis
(a benign bone diseasethat typically appears as an increasein
intramedullary bone opacity in young dogs) has a spectrum of
appearances. As the reader builds on experiencesof what panos-
teitis can look like, thesevarious patternsare placedinto the visual
cortex of the brain and stored as possibleradiographicpatternsfor
this diseaseprocess(Fig. 5-19). Initially, when one beginsto evalu-
ate radiographs, there is the expectation of being able to identify
the primary abnormalities.This also assumesthat the reader is
able to discriminate the abnormal changeson the radiograph from
normal images, and that the change seen on the radiograph fits
into the preconceivedcontext ofwhat the lesion is expectedto look
like. As the reader seesmore and more radiographs, this basic
knowledge expands, thereby providing a degree of confidence that
what the readeris looking at is normal or abnormal-
A systematic approach to interpretation
In this edition of Textbookof VeterinaryDiagnostic Radiology,there
are introductory chaptersto each of the various anatomic regions.
Thesesectionsinclude a basic approachor interpretationparadigm
for evaluating each area. A paradigm is defined as an example or a
model. In radiology, interpretation paradigms are a reflection of
D orsol atera l -P al maromedi aI
D L-P aMO
Figure 5-18, Descriptionof radiographrcprojectionsby the
d i r e c t i o no f t h e p r i m a r yx- r a yb e a m ,fr o m th e p o in to f r e fe r ence
t o t h e p o i n t o f e x i t (p r o xim avie l w o f th e e q u in eca r p a lb o nes).
( C o u r t e soy f D r .J . E . Sm a llwo o d .)
Introducti on
to R adi ographiInte
c r pr et at ion49
'7, \
iuu
i ' v FN ,
CRANIAL CAUDAL
<> -'Tarsocrural
lolnl
PNOXMAL
DISTAL
._..;
v
DOR S AL
Figure 5-17, Properanatomicdirectional
termsas they appryro vaflous
partsof thebody.(Courtesy
of Dr.J. E.Smallwood.)
the reader's approach to systematically reviewing a radiograph
basedon experience.The interpretiveparadigmspresentedhere are
not the only model of interpretation for evaluating radiographs.
These models, however, provide a basic framework on which a
systematicapproachto radiographicevaluationcan be built. Based
on the radiograph being a two-dimensional presentation of re-
gional anatomy, we must understand the inherent limitations of
our visual acuity in identif ing specific anatomic structures and
derangements.In Chapter4, an excellentoverviewofvisual percep-
tion is presented;the reader is strongly encouragedto thoroughly
digestthis information for the purposeof understandingthe limita-
tions of evaluating two-dimensional survey radiographs.Limita-
tions specific to a given location are stressedwithin individual
cnapters.
Radiology is a balance between scienceand art. The science
involves actual knowledge of radiographic production and the
identification of abnormalitiesbasedon the detailsof radiographic
anatomy, pathophysiology, medicine, and surgery. The art is a
function of the reader'sexperience(Fig. 5-20). To hone radio-
graphic interpretation skills, one has to understand the basicsof
making and interpreting radiographs. Additionally, as new infor-
mation is brought to the forefront, these new findings must be
incorporated into one's scientific database,and this information
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
interpretation,and thereby acquiresa better understandingof the
clinical significanceof certain radiographic abnormalities.As was
mentioned earlier,initial pattern recognition is important, but one
cannot experienceall of the possibleradiographic patterns that a
diseaseentity may have. Thus, the expectation is that even experi-
enced radiologistswiil regularly review radiographs that contain
D or s opal m ar
l rque al marol atc ralObl i que
D M - PaLO
30 30"
Later om edi al
LM
50 A ND PR IN C IPL EOF
P HY S I CS S IN T E R P R E TA TION

Experience "All'r Possibilities Over a Lifetime

Variations

Cla ssic
Examples

Be g in n e r

Figure 5-19. Intially,a readerwllLlearnwhat a particular

disease lookslikeinthe"class
process example
c" or textbook
of a dlseaseprocess.As readersevaluate manymoreradio-
graphicexamplesof thediseaseprocess, and
theirexperience
artof understanding
thevariations
is increased,whichexpands
theirlnteroretatron
abllitles.

new information. Unless one has been continually "renewing" his
or her visual cortex file cabinet, this new information cannot
alwaysbe interpreted correctly.
As has been described,the scienceof radiology forms the basis
for interpretation of radiographs.The basic tools for radiographic
interpretation include knowledge of normal anatomy' a systematic
approach to radiographic interpretation, utilization of the basic
radiographicsigns,and then tying all ofthese togetherto formulate
a differential diasnosis list. Once a differential list is established
and prioritized basedon signalment, physical examination findings,
and other clinical data, the next step should be to establish a
definitive diagnosis(Fig. 5-21). Although the goal is to establisha
definitive diagnosis for every patient, this may not alwaysbe neces-
sary or practical.
The art of radiology involves knowing how to tie all radiographic
abnormalities together into a specific conclusion. A radiographic
summary can be viewed as a collection of various changes or
radiographic abnormalities from the expected radiographic anat-

wk
\ ,\%"e_

Figure 5-2O, Initial radiographicevaluationis

depenoenton l 1e reaoer's\now l edge bas e of
basi canatomyand physi ol ogy, radi ographiphy
c s-
i cs, pat^ophysi oogyof di seaseproc es s esand,
basi cpri nci pl es
of medi cl neand su rgeryA
. s one
progresses of the
up the mountai nfor ev al uati on
'ad ographs,rl -e'e i s rore r^'o'rrari ongai red
throughexperrence s art of radi -
that representthe
ology.

" ii:lflN
y.9qL$u-*--.*:l["'r.*l'"p
-",rr*.ffi-:n.;;
Figure 5-21, The basic radiographictools for interpretation.The
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
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
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
becauseit is only a summary, not al1of the radiographic abnormal-
ities can be described(Fig. 5-22). Consider the lateral radiograph
of the thorax in Figure 5-22 from a l0-year-old Golden retriever.
Write a description of the radiographic anatomy present on the
radiograph.
Did your discussioninclude a description of each of the ribs,
the costal cartiiages,the sternebrae,the vertebral bodies, the gastric
axis, the right cranial lobar artery, the bronchus and vein, and so
forth? It is impossible to totally evaluate all of these specific struc-
tures in complete detail. This again emphasizesthe importance of
placing the radiograph on the view box in a specific manner each
time, enabling careful evaluation and systematic interpretation of
the radiograph.
I Evaluating radiographic
I abnormalities
After systematically evaluating the completed radiographic study,
the clinician should compile a basicdescriptionof the radiographic
abnormalitiesnoted. This step is often skipped by inexperienced
interpreters. It is important to recognizethat the ability to describe
the appearanceof the lesion, the location of the lesion, the radio-
graphic sign changes(including opacity), and any associatedradio-
dog. See text for ques
Figure 5-22. Right lateralthoraxfrom a 10-year-old
t i o na n dd e t a i l s .
Introducti on
to R adi ographiInter
c pr et at ion5l
$H$. .TP.
*on+**o"t\* {Lrx$$rs}t${tbr$sffissfr
***_
ffi;***"'*r{
D)Tyinsita,
noenfensions
)4L "'1il;;0"-"'n^
'
ll,1i,i,.J:,',,
ffJ:x
Approach ' Position/Location examination'
Ddx' Next Step'
{lnterpretation 'Margin/Conlour
etc )
Par adi gm ) ' Shape
graphic changessurrounding the lesion will lead the interpreter to
a conclusion regarding a differential diagnosis, possibly even a
primary differentiai diagnosis for the radiographic abnormalities.
However, if this does not work, the interpreter should develop a
summary list of all radiographic abnormalities detected. For each
of these abnormalities,based on the reader'sexperience,a certain
degree of importance should be assigned.According to this degree
of importance, abnormalities may be further evaluated.
A radiographic abnormality can be viewed as either a window,
a mirror, or a picture (Fig. 5-23). When the radiographic abnor-
mality is viewed as a window, the abnormality is considered to
have happened in the past. These historical changesmay or may
not be important or related to the reason why the patient is being
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-
biiity, and thereby ventral spondylosis deformans. This condition
is assessed as not necessarilybeing important for the immediate
problem. This information, however, should not be ignored; it
should just be placed lower on the priority list of the described
radiographic abnormalities.Assessinga radiographic abnormality
as a mirror assumesthe abnormalitv is important and is a reflection
of today'sproblem. Assessingthe iadiograph as a picture assumes
that the radiographic abnormality is significant today, but that it is
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
abnormality is going to be 100%osensitive,or its absence1007o
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

A radiograph can be viewed as a Picture' a Window or a Mirror ol

the Patient.
The Radiograph
as a Mirror:
A.^Il^^ri^.
^ {T^ i - ,/.
e,,.rant Pr n h l o m
-d%

@
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
to build stronger support for a given radiographic diagnosis. This
concept can be thought of as an inverted ice cream cone, called
the cone of certaintyt (Fig. 5-2a). At the bottom or base of the
cone are a number of possible differential diagnostic considerations
for a given radiographic abnormality. As one finds more radio-
graphic evidencefor a given diseaseprocess,the confidence regard-
ing a particular radiographic diagnosisincreases,thereby decreasing
the number of possible differential diagnostic considerations. If
one identifies very specific and sensitive radiographic abnormali-
ties, one reachesthe top of the cone and can have a high degree
of confidence that a specific diseaseis present.
In establishing a list of differential diagnoses,there is a reason-
able approach to listing possible causesof the radiographic abnor-
malities. The clinical context and signalment become important at
this time. When in doubt, one can use aids such as the mnemonic
acronym CITIMITV standing for congenital, inflammatory, tumor,
infectious, metabolic, iatrogenic, traumatic, and vascular' Using
this approach, one should be able to think of a specific etiology
for a given radiographic abnormality. For example, a solitary lung
noduie or mass in the left caudal iung lobe of a lO-year-old
Doberman pinscher is most likely a primary lung tumor. Other
diasnoses could be considered, but one must think of specific
*The concept of the cone of certainty has been adopted from Dr' Richard Pratt's
(Professor, Old Testament) lecture notes. Introduction to Pastoral and Theological
Studies. Orlando, Florida, Reformed Theological Seminary.
etiologies that truly cause disease in dogs. For example, other
considerations in this dog are inflammatory nodules such as a
solitary granuloma (parasitic, eosinophilic, or tuberculous) or a
solitary lung abscess.However, one must be able to prioritize
conditions included in the differential diagnosis list. Without pri-
oritization (based on experience,continuing education, and feed-
back), a laundry list of possiblediagnosesbecomesa roadblock to
effrcient attainment of the deflnitive diagnosis. When differential
diagnosis lists are formulated, it is critical that some ordering of
possibilities, based on the radiographic abnormalities present and
the probability of occurrence,be performed as well.
When interpreting radiographs, one should remember that the
radiographic appearancerepresentsonly a snapshotof the disease
process (Fig. 5-25). Clinical signs often precederadiographic
changes. Therefore, even though radiographs are normal, rapid
changescould develop and would be apparent ifrepeat radiographs
were made within a short period of time. Additionally, assessment
of how a patient is responding to therapy can be done using
sequential radiographs. Is the therapeutic intervention having any
effect on the radiographic appearanceof the disease?One should
compare apples with apples, meaning that using the same radio-
graphic technique in sequential radiographs is important. If the
radiographic changesdetected on a recheck examination have not
resolved as would be expected,then one should rethink either the
original differential diagnostic list or the therapy being used. Fi-
nally, if a radiographic abnormality is present and there is a
long differential list, a "next step" is usually necessary,as most

Gone of Certainty

Specificdiagnosis

Figurc 5-24, The cone of certaintyrepresentsthe degreeof confi-

Heartworm Disease dencea readercan pl aceon a gi venradi ographidi c agnos i sbas edon
. En la r g e d the radi ographiabnormalc i denti fi edon a gi ven ra di ograph.
i ti es For
b ,lu n te dp u lmonary
arteri es
exampl e,a general i zed i ntersti ti all ung opaci tycan havemany c aus es
. Big h th e a ret n la r g e ment from techni calto age-rel ated to di seasespeci fi c,and o ne w oul d be
. Pu lm o n a rnyo d u le s pl acedi n the w i dest porti onof the cone of certai nty(th e "unc ertai n"
. M a inp u lm o n a rayr te ryenl argement areaj ust basedon the srngl eradi ographiabnormal c o f an i nc reas e
i ty
i n i ntersti ti all ung opaci ty).Other radi ographiabnorm c s uc h as
al i ti es
. In te r stitia
lul n gd ise a se enl argement of the pul monary arteri es, tortuosi tybl unti ngof the pul mo-
nary arteri es,ri ght ventri cul arenl argement, and enl ar gementof the
mai npul monary arterysegmentw oul di ncrease our confi dencthat e the
lnterstitiallung opacityis relatedto heartworminfestationsecondaryto
an eosi nophi l i pneumoni
c ti s.
We have come to some v ery s pec i fi c
Non-specilicchange concl usi ons regardi ng the radi ographiabnormalc ho w ev er,i n the
i ti es,
contextof the otherradi ographichanges c that are prese nt,w e are hi gh
i n the coneof certai nty(verycertai n!labout ) our radi ogr aphidicagnos i s
of heartworminfestation.

Lifeline of a Disease Process
Incubation
Figure 5-25, This figure iilustratesthe lifelineof a diseaseprocess,
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-
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
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
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;
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;
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,
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 ) .
radiographic changesare nonspecific.For example,hepatomegaly
may warrant evaluation of serum chemistry or an abdominal ultra-
sound examination. Being able to know what to do next and how
to continue to assessthe patient for a particular diseaseprocessis
iust as important asbeing able to interpiet radiographic abnormali-
ties correctly.In essence,
radiology can be thought of as a screening
test for abnormalities, similar to evaluation of a blood count.
How one handlesthe information in establishinethe causeof the
abnormality becomes parr of the art and fulillment regarding
radiographicinterpretation.
Errors in interpretation
One can easilymisinterpret radiographic information., Subtle ra-
diographic changescan be overvalued or undervalued in the inter-
pretive process.Sometimes subtle clues are most important in
formulating the correct radiographic differential diagnosis. Several
tvpes of errors need to be taken into account:(1) errors of search-
ing or scanning, (2) errors of recognition, (3) decision-making
errors, and (4) egocentricerrors.r'2
Searching or scanning errors
Errors of searching or scanning result when the reader fails to
search the film in a systematic fashion and thereby misses the
radiographic lesion completely.Sometimesthese errors are called
corner errors becauseof the tendency to overlook lesionslocated
at the periphery of the radiograph as the centerpart of the radio-
eraph or the areaof interestis scrutinized.There is also a "satisfac-
tion of search" error that occurs when the reader has preconceived
ideas as to what should be present or absent on the radiograph.
Once the reader has assessedthe radiograph for this particular
abnormality, the reader becomes content or satisfied that the re-
mainder of the radiograph is normal, and stopsthe search.
Recognition errors
\ secondtype of error is the recognitionerror wherebythe abnor-
mality is seenand perceivedbut is not appreciatedas an abnormal-
it\'. This error is based on the reader'sprevious experienceand the
''art" of radiographic interpretation. The reader
is again warned
about the importance of understandingnormal radiographicanat-
om,v,normal anatomic variations, pathophysiology,and the myriad
of rvaysa particular disorder may appear radiographically.
Decision-making errors
Decision-making errors involve how we interpret radiographic in-
lbrmation and which radiographic abnormalities we decide are
rmportant. Some findings fall into a gray zone in which clinical
signilicance may or may not be known, even with knowledge of
the clinical information about a given patient.
Introducti on
to R adi ographiInter
c pr et at ion53
@
Fulminant
7 Disease \
/\
Earty@l /\
. Presentation Death
Gtinicatsigns
@l
\/\./
Intervention Recovery@l
\* / /
t
t
*6 ,. / /
i ntersri ti a'and
al veol ar
edema
lE --,-t
pul monaryvei nssmal l er;
edema resol ved
Egocentric errors
The final source of error is egocentric errors, by which we overesti-
mate our own grasp of the truth or we misapply the information
that we know Additionally, we may ignore cirtain radiographic
abnormalities that contradict our basit assumptionsand asJess-
ments regarding the radiographic abnormalities present on the
radiographs. A way around egocentric errors is to avoid reviewing
radiographs in a sterile, single-personenvironment and to seek
second opinions. In most settings, one can establish radiology
rounds in which multiple individuals can review radiographs. This
allows for quality control, thus decreasingthe likelihood of error
in_radiographicabnormality identification and interpretation.The
following is a twelve-step process that can be used to evaluate a
radiographic study. It can be modified and tailored to individual
preferencesso that it works for many different situations.
I Twelve-step process for
I radiographic evaluation
Preliminary work-diagnostic quality
1. Review all radiographs in an appropriate environment.
This includes a quiet, dark area that is free from distractions and
thathas an adequatenumber ofview boxesso that the entire study
can be viewed simultaneously. There should be accessto a ,,hot;,
light. The "hot" light r.ru., i-o funcrions.The first is to provide
additional illumination for evaluation of overexposed oi hish-
contrastareas(i.e.,lung fields,soft tissue-to-boneinterfaces, eti.);
the second function is that it forces the reader to focus on small
sections of_ the radiograph. The reader is not overwhelmed by
Iooking at the entire radiograph and is able to systematicallyreview
all parts of the radiograph in a "bite-size"section-by-sectionman-
ner. In evaluating radiographs, it is important to turn off all
overhead lighting and other view boxes that are not being used.
These "external" light sources distract the visual cortex from the
purpose at hand-evaluating just the radiograph(s)in question.
2. ldentify the study being reviewed and answer the fot-
lowing questions. What is the speciesof animal beins evaluated?
What is the anatomicregionof interestthat hasbeenraiiographed?
Are there additional radiographs available (special views or special
procedures) that also need to be interpreted? Is there a comDaratlve
study with which to compare the current set of radiographs?A
sample thought process might be: This is a recheck radiographic
examination of the thora-xperformed on 7lll00. Risht lateral,left
lateral, and ventrodorsal radiographs are available ior review (no
additional views or special procedures noted) and are compared
with the previous radiographicstudy dated 5/l/00.
54 P HY S I CS O F IN T E R P R E TA TION
A N D P R IN C IP L ES
3. Hang the radiographs the same waY ftncluding the or-
der) each and every time you review that particular radio-
graphic examination. Remember that one thing you have work-
itrg'fot you is your brain; pattern recognition within the visual
coite* becomesa key player in recognition of abnormalities' If you
consistently piace the radiographs on the view box in a specific
manner, you will start to identify abnormalities before starting
your systematic review of the radiograph(s) because your brain
i..ogrir.r that something is not the same as the expected normal
patte'rn for that particular study. This systemof Pattern recognition
bOgS NOf ,eplu." u systematicapproach to reviewing the radio-
graphs; however, it does provide the groundwork for organizing
evaluation of all
|ourself and the foundation for a systematic
radiographicimages.
l.-Mike sure that atl of the radiographs You have are
complete and appropriate for a given radiographic examina-
tion. For example, a thoracic radiographic study consistsof a right-
lateral, a left literal, and a ventrodorsai or dorsoventral view' If
there are limitations as to the number of radiographs that could
be obtained,be sure to note in the medical record of the patient
that an incomplete examination was obtained, along with the
reason(e.g.,thJpatient was dyspneicand a ventrodorsalor straight
dorsoventralwas not made).
5. Evaluate patient positioning' This should include the ana-
tomic boundaries of the area of interest (e.g.,Is the entire thorax
included in the study?) and any obliquity that may hinder accurate
interpretation of a given radiograph. Know your limitations from
the start. Positional troughs are available for placing dogs and cats
in dorsal recumbency to obtain ventrodorsal radiographs of the
thorax, abdomen, vertebral column, or pelvis'
6. Evaluate the radiographic technique. Are the films overex-
posed or underexposed? If the answer is yes, is the over- or
-underexposure
secondary to a disease?If that answer is yes, then
one should not attempt to adjust the technical factors, but treat
the patient first and then obtain a radiographic study after. a
diagnosticprocedurehas been done. For example,in a dog with
pne'umothoiax, the study will more than likely appear overexposed'
in a dog with severepleural effusion, the study will appear under-
exposed.Repeatradiographs should not be attempted untii the dog
has undergonethoracocentesis. Technicaladjustmentsmay not be
necessary.For technical adjustments, severalrules,of thumb are to
decreasethe kilovoltage peak (kVp) by 15o/oor reduce the milliam-
pere seconds (mAs) by SoTofor an overexposedradiograph, and
io increase the kVp by 75Voor increase the mAs by a factor of 2
for an underexposid radiograph. \A4rich adjustments you use will
depend on the type of study (anatomic region), considerationof
latitude ,rersuscontrast, and technical factors that might limit these
adjustmentsbased on the type of x-ray generator one has' One
should avoid m)anipulating both the kVp and mAs at the same
time.
7. Evaluate for other technical errors and artifacts that
might hinder your interpretation of the radiographs' Proc-
essine artifacts and technical errors can complicate and hinder
interpretation of radiographs. Technical errors in the darkroom
can iotally destroy a high-quality radiograph. Be sure to review
and change darkroom technique so that high-quality radiographs
can be obtained on a consistent basis. An overview of darkroom
technique is provided in Chapter 1. Readersare referred to refer-
encesprovided there for information on overhaul of the darkroom,
7 lymphadenopathy could be summarized as being most likely repre-
if this is neededin their practice.5
8. Continuously review the normal radiographic anatomy
that is present on the radiographs' Review radiographs in a
systematic fashion as presented in the interpretation paradigm
.irupt"., for a specific iection. Review the entire radiograph, and
reviw each radi,ograph using the same process' Refer to anatomic
aids and textbooki when reviewing radiographs (see Chapter 50)'
One must be able to recognize normal anatomy to identifr radio-
graphic abnormalities.
Disease detection and description
9. ldentify the radiographic abnormafi'tres' Determine if a
structure is abnormal by using the changes from the expected
radiographicsignsor findings for a given structure (seeFig.5-21).
Radiographic signs include changes from the expected number,
size,shape,number, location,margination,and opacity.Thesebasic
changesin the expected normal radiographic anatomy result in a
iist of radiographic abnormalities. At this point, one must deter-
mine if the abnormality identified is relevant or not. Do not
discount any abnormality until all radiographs are evaluated and a
complete list of radiographic abnormalities has been established.
Remember that the descriptions used to characterizeradiographic
abnormalities may be subjectiveand somewhat arbitrary (e.g., mild
interstitial lung opacity). Also remember that the existence of a
radiographic abnormality does not mean that it is clinically rele-
vant at this particular time. The abnormality may represent an
anatomic variant or reflect a Past event (window) or current disease
state (mirror), or it may be a predictor of future outcomes (pic-
ture). Clearly, the last two types of abnormalities are the most
important findings that have to be recognized before one reaches
a conclusion regarding the radiographic changes,taking into ac-
count the signalment and clinical findings and history.
Differential diagnosis/radiographic diagnosis
10. Establish a list of differential diagnoses for the radio-
graphic findings. At this point in time, it is important to deter-
mine if any of the radiographic abnormalities that have been
identified can fit into one disease or a group of diseases.For
example, there are many differential diagnostic considerations for
right ventricular enlargement; however, in conjunction with en-
larged, blunted, and tortuous pulmonary arteries,heartworm infec-
tion becomesa likely possibility. Use the history and signalment to
help establish and prioritize the differential diagnosis. It is im-
portant to understand the pathophysiology behind the radiographic
changes so that one can tie different radiographic abnormalities
together as a single diseaseentity. The goal of clinical medicine, in
addition to establishing a radiographic diagnosis, is to bring all
availableinformation together and settie on one or two conditions
that are consistent with all the abnormalities. A pitfall of radio-
graphic descriptions of the abnormalities is that all differentials
listed for interstitial lung diseaseare not relevant to every patient
in which interstitial lung diseaseis diagnosed, the reason being
that the clinical context of the patient's signaiment and history
must be taken into account before the differential diagnosis list is
prioritized. If the radiographic abnormalities are specific and are
high in the cone of certainty, make a definitive diagnosis.Recognize
that this will not be a common occurrence, and that a well-
thought-out differential diagnostic list is often a necessity.Again'
however, this differential list should not be an 'Aunt Minnie"
approach to the radiographic abnormality, but should include very
real possibilities for a given patient.
ti. Ma*e a radiographic diagnosis. Incorporate the clinical
history, physical examination findings, and signalment when mak-
ing a radiographic diagnosis.This radiographic diagnosis must
incorporate al1of the radiographic abnormalities identified and try
to tie them into one clinical disease entity. For example, the
radiographic abnormalities of perihilar and sternal iymphadenopa-
thy, interstitial lung disease,hepatosplenomegaly,and medial iliac
sentativeof generalizedor systemiclymphoma. There will be times
that the reader will discover something on the radiographs that is
clinically important, but that may not have anything to do with
the current clinical history or presentation. DO NOT ignore these
radiographic abnormalities; instead, because of their significance,
pursue these changes as part of the patient's diagnostic work-up.
In other words, these abnormalities must be added to the working
problem list of the patient.
- :G

Next step recommendation
12. Make a recommendation or give thought to the nert
step in patient management. This might include or involve (1)
additional imaging studies that would confirm the presence or
absenceof a disease (e.g., a suspectedgastric mass would be
confirmed by obtaining a 1eft lateral radiograph with air in the
pyloric outflow tract that might outline the mass); (2) special
oblique radiographs that may allow one to better visualize a sus-
pected abnormality (e.g.,horizontal-beamradiographsto confirm
the presenceof free air in the abdomen,or oblique radiographsof
the thorax to highlight a destructive rib lesion); or (3) special
proceduresthat will confirm the presenceor absenceof a disease.
These could include alternate imaging proceduressuch as ultra-
sound, nuclearmedicine,computed tomography,or magneticreso-
nance imaging. Additionally, ask yourself what other clinical tests
need to be performed to establish the definitive diagnosis. This
t1pica1lywill involve needle aspiration and biopsy of the abnormal
organ or structure.This could also involve repeatradiographsover
time to see how a lesion is responding or is not responding to
therapy.Ifthe appropriateresponsehas not taken place,one should
review the radiographs and start the process all over again, to
ensure that nothing was missed and that the differential diagnoses
rvere in the appropriate order.
In summary, radiographic interpretation is a systematicprocess
of reviewing a radiograph in a pre-establishedmanner. Once an
abnormal pattern is recognizedand described,a rational thought
processleads one to reasonabledifferential diagnostic considera-
tions from the standpoint of known pathophysiologicprocesses
that occur within the speciesin question (Fig. 5-26). In the final
Figure 5-26, Summaryof radiographicinterpretation.Interpretationis
r 3 p e n d e n to n : A , t e ch n icaco l n sid e r a tio nds,a r kr o o ma, n d p osi ti onl ng;B,
- o r m a l r a d i o g r a p h an
i c a to m ya n d p h ysio lo g yiC, p a th o p h ysi ol ogy
: e c t e d r a d i o g r a p hic ch a n g e sa sso cia te dwith d ise a se ,D, interpretati on
: a r a d i g m sa n d a p p ro a chto r e vie wo f th e r a d io g r a p h s;
r a g n o s t i c o n s i d e ra tio nBe s. ca u seo f e r r o r sin in te r p r e ta tion
: ^ e s e p o i n t s ,i n c o r re ctin te r p r e ta tioann d a n ln co r r e ctd ia g nosi sresul t.l t
: m p o r t a n tt o r e me m b e rth a t a ll in te r p r e ta tio nasr e b u t summary,and
s - m m a r i e sa r e a l w a vsDa r tia l.
Introduction
to Radiographic
Interpretation55
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
diachronic trace. Within this lifeline is the life of a specific disease
processthat undergoesa preclinical incubation period before the
patient developsan illness.It is at this time that a synchronicslice
is obtained (i.e.,blood work and radiographsare done that give us
a snapshot of the diseaseat that particular time). At this time,
we run through the process of interpretation and we review the
radiographs. We recognizethat we must have a basic understanding
of radiographic anatomy and normal physioiogy, as well as of the
pathophysiology behind radiographic changes that are seen in a
given diseaseprocess.
The approach to radiographic interpretation is dependent on
our using the specific tools with which we have been equipped for
evaluating radiographs. These include a basic systematic approach
or interpretation paradigm and a method for evaluating each struc-
ture using the six basic radiographic anatomic signs.Once radio-
graphic abnormalities have been established, a list of differential
diagnosesis formulated and a possibleradiographic diagnosisis
establishedbasedon the abnormalitiespresent.More importantly,
the next step in working up a patient is determined. This step
should move us through the information gap to the truth as to
what the disease actually is that is causing the patient's clinical
signs.
At this point, we need to step back and look at the process
(labeledA through E, see Fig. 5-26). Each step has the potential
for error on our parts, whether it is poor radiographic technique
or missing important radiographicabnormalities.Thesecan result
in an incorrect interpretation and thereby move us farther from
Interpretation is dependent on a four.step process:
Detection, Description, Deviation from Normal, and
Disease or Differentials.
TIMELINE
Birth CureoI Death
disease
resolution
Viewerwith
radiograph
Mishandling of the Information
and ex-
yourgraspofthetruth.
1) 0verestimating
a n d E di fferenti al 2) Misapplying
thetruthyouknow.
at any one of yourmindto thefactsthat
3) Closing
cthatyouassume.
contradiw
56 P HY S I CS OF IN T ER PR ET A TION
A ND P R IN C IP L ES

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
I S pine
-\t the completion of this section,the readershould be able to:
1. Identify the radiographic anatomy of the spine in the dog,
.at, and horse.
2. Select the appropriate radiographic views for the different
regionsof the spine in small animals and the horse.
3. Identif images of the spine that are of diagnostic quality.
4. Use.a systematicapproach to the interpretation of spine
raclograpns.
5. Be aware of the application of different alternate imaging
techniquesfor assessing the spine.
Anatomy
There are five anatomic regions of the small animal and equine
spine (Fig. 6-7A and B): celvical, thoracic, lumbar, sacral, and
caudal. Each spinal region has distinguishing characteristics,and
these can direct the viewer away from or toward possible radio-
gra ph ica bn orma lit ies ( Figs .6- 2 and 6- 3 ) .
and dis eas es
Cervical spine
Dog, cat, and horse. Cl has no spinous process,but it has
iarge transverseprocesses,sometimesreferred to as "wings" (Fig.
6-a). C2 is the largest vertebra. It has an odontoid process from
the cranioventral aspectofthe body, calied the "dens." The spinous
processof C2 should overlap the arch of C1 (see Fig. 6-a). C6
has large transverseprocesses,sometimes called ventral laminae
fig. 6-s).
Thoracic spine
Dog and caf. There.are 13 pairs of ribs. T11 is the anticlinal
vertebra; its spinous processis vertical rather than angled cranially
or caudally (Fig.6-6). T10-11 is the anticlinal space;this is the
most narrow thoracic intervertebraldisc space(seeFig. 6-6).
Horse. There are 18 pairs of ribs. Owing to the large size of
adult horses,the (dorsal) spinous processesare the only part of
the thoracic spine that can usually be evaluated radiographically;
this is typically done in the lateral view. Irreguiar margination of
the dorsal aspectof the spinous processis normal; it is the result
of incompleteor irregular mineralization of a secondarycenter of
ossification.
Lumbar spine
Dog and caf (Fig. 6-7). The cat has long lumbar vertebral
bodies when compared with the dog (Fig. e-S). f" other words,
the ratio of vertebral body length to height is greater in the cat
than in the dog.
Sacrum and caudal spine
Dog and cat. The three sacral segmentsare normally fused (Fig.
6-9). Caudalvertebraemay havehemal arches(Fig. 6-10). Median
sacral vesselsare surrounded by the hemal arches.The archesmay
b-epartial or complete and are more commonly seen in cats. They
should not be confused with spondylosis deformans or fractures.
Ligamgnts of clinical significance-smalt
animal (Fig.6-i1)
Gervicalligaments
The ligaments of the cranial cervical spine help maintain the
alignment and stability of CI-C2; some prevent impingement of
the- spinal cord by the dens. If these ligaments arJ damaged or
defective (congenital anomaly), atlantoaxial instability may result.
Thoracic ligaments
The intercapitalligaments(seeFig. 6-11) join the headsof a given
pair of ribs, crossing from one side to the other over the dorsal
aspect of the intervertebral disc. Often these lieaments are not
present on the first pair or the last pair of ribs,"Theseligaments
tend to keep the thoracic intervertebral discs in situ.
Entire spine
The dorsal longitudinal ligament is located along the floor of the
vertebral canal. When hlpertrophied, it may be associatedwith
cervicalvertebralmalformation-instabilitv svndrome.
Miscellaneous
The intervertebral discs technically are considered ligaments. They
are composed of the outer annulus fibrosus and the inner nucleus
pulposus. Common clinical conditions that involve the interverte-
bral discs include intervertebral disc diseaseand discospondylitis.
Radiographic technique and positioning
Becauseof the radiographiccomplexityof the spine,it is imperative
that images are made using the correct exposure and that the
Text continued on page 62
57
58 AXIALSKELETON

Cervical

Lumbar

Figure 6-1. B, The vertebralformulaof the dog and cat is C7-T13-17-53-Cd2O-24

A, The vertebralformulaof the horseis C7-T18-16-5S-Cd15-20.

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

Figure 6-3. Lateralradiographof an equinecervica vertebra.This is C3 based

o n t h e p r e s e n c eo f th e la r g esp in o u sp r o ce sso n th e ve r te b rai mmedi atelcrani
y a.

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.

Figure 6-5. Lateralview of caninecervicalva.tohra 1-6 l\lnto ho 12roa t.anS-

: - : 5 o ' o c e s s e sc h ar a cte r isroici th is ve r r e b r a .
60 A X I A LS K E LET ON

-'';"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:

Figure6-6. L a te r avie vertebrai sTl l ,andtheanti cl i nalspacei sTl 0-T11

l wo fth e th o r a cicsp in e o fadog.Theanti ci i nal

iiirilil:.,:,

9.L::':':l::::::
:ii@utii1111,
ll!.:::.
l..,ili

Figure 6-7, A, View of a norma caninelumbarspine.

B , The i rregul arand sl i ghtl yi ndi stnctventralmargi no f
L3 (andal sopresenton L4 but not vi si bl ei n thi s i mage)is
normaland i s dueto the attachment of the di aphragma ti c
crura.Thi s normalappearance shoul dnot be confused
with bone erosionowinq to a tumor.
 Interpretati on
P aradi gms
for the A xi alS kel eton-S maland
l Lar geAnim al 6l

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

Figure 6-9. Normal lateral (left) and ventrodorsal 1rghtl

" : C i o g r a p hosf t h e ca n in esa cr u mT
. h e th r e esa cr a se
l g m e n ts
: ' e u s u a l l yf u s e d .

Figure EIO. Hemalarches(arrowheads)

in a doo
62 A X I A LS K E LE T O N

Alarligaments

IntercapitaI
ligament

Dorsallonoitudinal
ligamenl
of ligamentsof clin-
Figure 6-11. Schematicrepresentations
i calsi gni Icance.

patient is well positioned. It is very easy to misinterpret structures Protocol

on images of the spine that are of marginal or poor technical
quality. For these reasons,profound sedation or general anesthesia
is generally required when spinal radiographs are made.
There are many excellent referencesthat review the radiographic
positioning of small and large animals. A complete review of
patient positioning is beyond the scope of this text; therefore, the
reader is directed to the reference section of this chapter for more
information on this subiect.
Routine views in small animals
Two views are typically made-lateral and ventrodorsal views. The
lateral view selected(e.g., right versus left) is not critical, but it is
important that the same lateral view is used when repeatedroutine
radiographs of the spine are made to aid in the processof pattern
recognition.
Collimate to include the anatomic region of interest. For the
cervical spine, center ar C3-4 and C6-7. For the thoracic spine,
centerat T6-7.For the lumbar spine,center atL3-4. A radiograph
centered at T13-L1 is also beneficial.
Gorrect positioning
For the lateral view the transverse processesand the thoracic rib
heads should be superimposed.The intervertebral foramina should
be ofconsistentsize.Only one curvedline representingthe junction
of the transverse process with the vertebral body should be seen
(Figs.6-12 and 6-13).
For the ventrodorsal view, the spinous processesshould be
aligned and should appear centeredover the vertebral body (Fig. 6-
14).

Figure 6-12. A correctly (A) and in-

u:iii6tt) correctly /B/ positioned lateral radio-
r.,,rli5lll:
llll-,ri6l9lll:
%tol graph of a cani nethorac i cs pi ne. In
%.:l ,,rirarrr:arllqu
irrr::ll;ll!
tt9u:u r9:lllollsrr:
9llrl.iii6l
;|9lr.ii
R _ha +ranc\/arca nrn.pqqaq afe not
superimposed,and the accessorypro-
cess of tne vertebraea ' e s Lperi m-
posedover the intervertebral
foramen.
 Interpretati on
P aradi gms
for the A xi alS kel eton-S maland
l Lar qeAnim al 63

Figure 6-13. fhe blackline illustratesthe positronand shapeof the junction

of the transversp e r o ce sswith th e ve r te b r abl o d y.T h isju n cti oni s cl earl yseen
i n t h e v e r t e b r ac a u da to
l th e o n e co n ta in in q lh eb la cklin e .

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@

Figure 6-15, Radiographic examinationof the equinecervical

d ir e cte db e a m ( A) a n d a ve r tica ll ydi
: : n e u s i n ga h o r l zo n ta lly
-:cied beam /B/.
64 AXIALSKELETON
help one to become more organized in approaching the task of
evaluating radiographic examinations of the spine.
1. Carefully evaluate paraspinal structures.
2. Note if images were made under general anesthesia(should
seeendotracheal tube if neck or thorax included) or, if the patient
is a horse, if a standing position was employed for a tranquilized
oatient.
3. Count the vertebrae within each anatomic region.
4. Note the general size of the vertebrae for each region; they
should be approximately the same size as adjacent vertebrae in a
given region. Cl and C2 are exceptions.
5. Evaluate the dorsal and ventral alignment of the vertebral
bodies and the lamina.
6. Note the overall vertebral canal diameter, as weli as the
vertebral canal diameter at each vertebral body and adjacent inter-
vertebral disc space.
7. Evafuateeach spinous processand articular processjoint.
8. Assessthe overall size of each intervertebral disc space and
end plate,and evaluatedisc opacity.
9. Compare the size of adjacent intervertebral disc spaces.
10. Compare the size and opacity of adjacent intervertebral fo-
ramina,
:i11€
Figure 6-16, Radiographsand a transversecomputed
tomography(CT)imagesof a lumbarvertebraof a dog with
vertebralneoplasia.Invasionof the vertebralcanalis more
readi l yvi sual i zed
on the C T i mage.
Alternate imaging
Owing to the anatomic complexity of the spine, alternate imaging
modalities are useful for a complete evaluation of the small animal
spine and the equine spine.
Gomputed tomography
Computed tomography (CT) is useful for evaluating the spine
becauseit allows visualization of the spine without superimposition
of other bony structures. In addition, image contrast can be manip-
ulated to highlight the structure of interest (e.g.,bone versussoft
tissue). Spinal trauma and neoplasia are good clinical examples of
the utility of CT (Fig. 6-16). CT often provides accurate informa-
tion on the extent of spinal involvement becausethe vertebrae can
be evaluated in various imaging planes and without superimposi-
tion.
In many patients, CT can be used to detect herniated interverte-
bral disc material in the vertebral canal without the need for a
myelogram.
Becauseof the large size of the adult equine neck and the fixed
size of the bore of a CT scanner, only the most cranial portion of
the spine of the horse can be evaluated using CT. The entire neck
of a pony or foal may fit into the CT gantry.
Figure 6-17. SagittalT1- (top) and T2-weightedimages of a canine
spi neand spi nalcord.In T2 i mages,w ater i s characteri zedb y a hi ghs i gnal .
C erebrospi nal fl ui d can be seen aroundthe cord,and i n the c entralc anal
/8/.The nucl euspul posusof the i ntervertebral di sc al soha s a hi ghs i gnal ,
indicatingit is hydrated.(Courtesyof lan Robertson,BVSc.)

Figure 6-18. Bone scans. A contains3 lateral
i m a g e so f t h e e q uin ece r vica isp in e .An d B is a
d o r s avl i e w o f t h e ca n in elu m b a rso in e .T h e in te n se
r e g i o no f r a d i o a c t ivity
in B s d u eto r a d io p h a r m a ce u -
t i c a n t h e u r i n a r ybla d d e r .
Magnetic resonance imaging
Magnetic resonanceimaging (MRI) is acceptablefor evaluating the
osseousstructures of the spine, but it is better suited for evaluation
of soft-tissuestructures,eipecialtyintervertebraidiscs and the spi-
nal cord (Fig. 6-17). Myelographycan often be avoidedwhen MRI
is used to evaluatethe spinal cord. MRI has the same advantageas
CT in that the spine may be evaluated in various imaging pianes
and without superimposition of other structures.
Becauseof the large size of the adult equine neck and the fixed
size of the bore of an MRI unit, only the most cranial portion of
the spine of the horse is generally imaged. The entire neck of a
pony or foal may fit into the MRI unit.
Nuclear scintigraphy
Nuclear scintigraphy (bone scan) of the vertebrae often allows
detection of vertebral bone chanse before it is visible on conven-
tional radiographs. Areas of incieased physiologic bone activity
appearas regionsof increasedradioactivity (hot spots);conversely,
areasof decreasedphysiologicbone activity or bone loss appearas
regions of decreasedradioactivity (cold spots). Becauseof the
decreasedanatomic detail that is inherent in nuclear scintigraphy,
additional imaging studies such as radiographs or CT often follow
scintigraphicexamination (Fig. 6-18).
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.
Figure 6-19. Lateralradiographof a canineskull.
Interpretati on
P aradi gms
for the A xi alS kel eton-S maland
l Lar geAnim al 6s
A
B
2. Know how each radiographic view of the skutl is obtained.
3. Know which views constitute common radiographic examina-
tions of the small animal skull and equine skull.
4. Use a systematic approach for interpretation of skull radio-
graphs in smail animals and the horse.
5. Be aware of the application of alternate imaging techniques
-
for assessing the spine.
Radiographic technique and positioning
Radiographs of the skull are made with the small animal patient
under general anesthesia.General anesthesiais required because
small amounts of unwanted obliquity can causemisinterpretation.
Radiographs of the equine sku1l are typically made in the standing
tranquilized patient. It is important to remember that a small
amount of obliquity can cause severe anatomic distortion. Also,
when the skull is imaged, it is important that a f,lm-marking
system be establishedthat is consistent and understood by all who
use it to label oblique views.
The following views of the small animal skull are routinely made
dependingon the purpose of the radiographicexamination:
Routine examination: Iateral (Fig. 6-19) and ventrodorsal (VD)/
dorsoventral(DV) (Fig. 6-20)
:eu
au,:
n,lto"ril;
hrlla .; "
Figure 6-2O, Ventrodorsalradiographof a canineskull
66 AXIALSKELETON

of thefrontalsinusesin a dog.
caudalradiograph
Figure 6-21. Rostral

Nasal series:lateral, VD/DV rostrocaudalfrontal (Fig. 6-21)' in-

traoral DV of nasalcavityt Fig.6-22)
Bulla series:lateral, VD/DV open mouth rostral caudal (Frg- 6-23), Figure 6-23. Open mouth rostral caudal radiographof tympanic bulla in
left dorsal-right ventrai oblique, right dorsal-left ventral oblique a dog.
(Fig.6-2a)
Maxiila: lateral, VD/DV, intraoral DV left dorsal-right ventral
oblique (Fig. 6-25), right dorsal-left ventral oblique
Mandible: Lateral, VD/DY intraoral VD, left dorsal-right ventral
oblique, right dorsal*left ventral oblique (Fig.6-26)
For radiography of the equine skull, lateral views (Figs. 6-27
and 6-28), dorsoventral views (Fig. 6-29), and oblique views of
the nasal cavity, sinuses,or frontal region are typically made.

Variants
The different skull types in the dog (brachycephalic,mesaticephalic'
and dolicocephalic) may causesimilar structures to appear different

Figurc 6-24, Obliqueview of the tympanic bulla and tympanomandibular

j oi ntsi n a dog.

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

Figure 6-26. Obliqueview of the mandiblein a dog

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 6-27. Lateralradiographof the equineskull

Figure 6-28. Lateralradiographof the gutturalpouch regionln a horse Figure 6-29. Dorsoventralradiographof an equineskull
68 AXIALSKELETON

Fi gure 6-30. N asaltumor i n a dog. C onventi onalopen-

mouth radiograph(A) and a transversecomputedtomography
image /8/. These imagesare from differentpatients.

Figure 6-31. A horse positionedfor a computedtomographyiCT)examina-

t ion o f t h e s k u l l .N o t e t he sp e cia lizeta d b le o n wh ich th e h o r se i s l yi ng.C T
t abl e st h a t a c c o m p a n yt h e sca n n e ra r e n o t ca p a b leo f su p p o r tingthe w ei ght
of an a d u l th o r s e .

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
Figure 6-33, Ultrasoundimageof hydrocephalus
in a dog
2. Evaluate each image for correct radiographic technique and
positioning.
3. When reviewing a group of images, look for the same struc-
tures on all views; do not try to read one view in its entirety, then
the next, and so on. It is too difficult to remember all findinss
seen and to correlate them with multiole views.
4. Divide the skull into regional iections: maxiila and teeth,
maxillary and frontal sinuses,nasal cavity, calvarium, temporoman-
dibular joints and bullae, basioccipital and basisphenoid bones
(equine), mandible and teeth, pharynx, lar1'nx, gutturai pouch
(equine), and cervical spine.
Alternate imaging
Owing to the anatomic complexity of the skull, alternate imaging
modalities may be useful in expanding the evaluation of the small
animal skull and the equine skull.
Gomputed tomography
Computed tomography is a good imaging technique to use for
evaluating the small animal or equine skull (Fig. 6-30). With CT,
the skull may be visualized at different anatomic levels (e.g., nasal
cavity, forebrain, midbrain) and in different planes (e.g., transverse,
sagittal, dorsal) without superimposition of other structures; also,
Figure 6-34
for the AxialSkeleton-Smalland LargeAnimal 69
contrast is optimized with this technique for visualization of the
structuresof interest(bone versusbrain).
A horse head will fit into a standard CT scanner; however, a
special table that will accommodate the weight of the patient and
that will move in selectedincrements is neceisary (Fig. 6-31).
Magnetic resonance imaging
Magnetic, resonance imaging is excellent for revealing anatomic
is the imaging modality of choice for the lrain (Fig.
9.?11 T_d
6-32). The use of different pulse sequencesallows differentiation
between tissue and fluid types (e.g., edema versus cerebrospinal
fluid versus hemorrhage). Ferromagnetic contrast medium (gado-
linium-diethylenetriamine-penta-acetic acid IDTpA] ) is often*used
to further enhance structures of the brain. The bones of the skull
can be identified and examined using MRI; however, CT is a better
choice for evaluation of the skull. A horse skull will fit into a
standard MRI uniq however, a special table that will accommodate
the weight of the patient and will move in selected increments
rs necessary.
Nuclear scintigraphy
Nuclear scintigraphy may be used to evaluate the bones of the
skull. Scintigraphy has also been found to be valuable in identifiing
bone remodeling associatedwith sinusitis, or abnormalities of thi
teeth such as root abscesses.
Ultrasound
Ultrasound is not commonly used to evaluate the skull. It can be
used to assessbone margins of the skull. However, ultrasound may
be useful in evaluation of the brain. Examination for hydrocephalus
may be performed through an open fontanelle (Fig. 6-33). -
ffi Ouestions
l. Identi$' this vertebra (Fig. 6-34).
2. Identift the spinal region and species(Fig. 6-35).
3. 'vVhatis the vertebral formula in the doe and cat?
A. C6-T | 3-L7 -53-Cd20-24
B. C7-T 14-L7-53-Cd20-24
c. c7 -T 13-L7 -53-Cd20-24
D. C6-T 13-L7 -Ss-Cd20_24
E. None of the above
 )]]9;q
iiltrrr:rii.l
it:':uti
::::ll'.).).
t'l,,,,l :,...ili: :r116ll:
ii

Figure 6-38

Figure 6-39
4. \44ry is intervertebral disc diseasein the dog and cat uncom-
mon from T1-T10?
A. The ribs keep the discs in place.
B. There are no intervertebraldiscsfrom T1-T10.
C. Intervertebraldiseaseis very common from T1-T10.
D. The intercapital ligaments help keep the discs in place.
E. None of the above
5. Using Figure 6-36, identi$' the parts of the vertebra.
Identify the imaging modalitieson Figure 6-37.
7. Identify the following structures (dog skull) on Figure 6-38.4
ffi CHAPTER
ffi7
ffi The Granialand Nasal
ffi Gavities-Canine and Feline
w r Lisa T.Forrest
I Normal anatomy
The skuli is composed of numerous bones, some of which are
fused together. It encompassesthe brain and houses the sense
organs for hearing, equilibrium, sight, smell, and taste. The skull
provides attachment sites for teeth, tongue, larynx, and muscles.'
There is breed variation in the shape of the skull, with variation
being more pronounced in the canine species.Three terms are
used to designatethe different shapes.Dolichocephalicbreeds have
1ong, narrow heads with an extensivenasal cavity from rostral to
caudal. Examples of dolichocephalic breeds include collie and Rus-
sian wollhound. Mesaticephallcbreeds have heads of medium pro-
portion and include German shepherdsand Beagles(Fig. 7-l).
Brachycephalicbreeds have short, wide heads.Examples of brachy-
cephalicdogs include Boston terriers and Pekingese. Cats are more
uniform in their skull conformation. However, Siamese tend to
have longer heads as compared with Himalayan and Persianbreeds.
Calvaria and assooiated structures
The calvaria comprises the bones of the brain case, with the
occipital bone forming the base of the skull. The occipital crest is
The C rani aland N asalC avi ti es-C ani ne
a nd Feline 7l
and B: frontal sinus, tympanic bulla, coronoid process(vertical
ramus) of the mandible, soft palate,and nasalturbinates.
8. Identify the following structures (horse skull) on Figure 6-39:
stylohyoid bone, epiglottis, guttural pouch, ethmoid turbinates,
and coronoid process (vertical ramus) of the mandible.
9. How many views are required for a small animal nasal series?
Name the views.
10. Tiue or False. Examinations of the skull are commonlv per-
formed in an awake animal.
Answers begin on page 727.
the most dorsocaudalaspectof the skull (see Fig. 7-l), and the
occipital condyles are caudoventral as seen on lateral radiographs.
The foramen magnum is centered between the occipital condyles.
It forms a ring for passageof the spinal cord.
Nasal passages and paranasal sinuses
The nasal passageextends caudally from the external nares to the
cribriform plate and nasopharynx. The cribriform plate is a sieve-
like partition between the rostral olfactory bulbs of the brain and
the caudal nasal passage.The nasal passageis divided in half by
the nasal septum and is filled with thinly scrolled conchae. Cau-
daliy, the nasal septum is bony and fuseswith the cribriform plate;
it becomescartilaginous as it extends rostrally.l The vomer bone is
unpaired and forms the caudoventral part of the nasal septum.
It is the bony nasal septum and vomer bone that can be seen
radiographically.'zBoth dogs and catshave frontal sinuses(seeFig.
7-i), laterai maxillary recesses,
and small sphenoidalsinuses.These
are named for the bones in which thev are located.
72 AXIALSKELETON

Tahle 7-1. Dental formulas for the dog and cat

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, incisor teeth; C, canine teeth; M, molar teeth; e premolar teeth.

Figure 7-1. Lateralskull radiographof a Germanshepherddog, which is a
mesaticephalicbreed. Note the occipital crest (small arrowhead),superim-
posedfrontalsinuses(*), and tympanichullae(largearrowhead).
Tympanic bullae and temporomandibular ioint
The tympanic bullae (see Fig. 7-l) form the ventral part of the
temporal bone. Theseair-filled cavitiesof the middle ear communi-
cate with the nasopharynx via the auditory tube. The temporal
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
dorsal to the tympanic bulla and is composed of densebone in the
mature animal. The squamous portion of the temporal bone ex-
tends rostrally and laterally to form the zygomatic arch.
The temporomandibular joint is a condylar joint. The temporal
portion consists of the zygomatic processof the squamous temPo-
ral bone, which forms the mandibular fossa and the retroarticular
process. The retroarticular process is the ventral extension of the
squamous temporal bone. The mandibular aspect of the joint
includes the condyloid process,which articulates with the mandib-
ular fossa.
Teeth
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'
Components of the tooth include the root (embeddedin bone)
and the crown (within the oral cavity); the bone between teeth is
referred to as the alveolar crest. The dentin, enamel, and lamina
dura of the tooth are radiopaque. The pulp cavity and periodontal
membrane are of soft-tissue opacity (Fig. 7-2). The size of the
pulp cavity changes with maturity, becoming smaller with age.'
Specificson radiographic technique and positioning for tooth eval-
uation can be found eisewhere.*t
I Gongenital anomalies
Hydrocephalus
Hydrocephalus is an excessiveaccumulation of cerebrospinal fluid
within the skull. Congenital hydrocephalus may occur secondary
to structural defectsthat either obstruct cerebrosoinalfluid outflow
or impede its absorption. Canine breeds affected with congenital
hydrocephalus include the Maltese, the Yorkshire terrier, the Eng-
lish bulldog, the Chihuahua, the Lhasa apso, the Chinese pug, the
the Pekingese.sHydrocephalus has rarely been reported in cats.e11
Radiographic signs associatedwith hydrocephalus include dom-
ing ofthe calvaria and cortical thinning, persistent fontanelles, and
a homogeneous appearanceto the brain, resulting from the loss of
normal convolutional skull markings (Fig. 7-3). Previously,diagno-
sis of hydrocephalus was made by ventriculography," but this
invasive procedure has been replaced by computed tomography
(CT), magnetic resonance(MR) imaging, and ultrasonography."-'u
Persistentfontanelles allow the use of ultrasound to diagnose hy-
drocephalus,l3'raand normal ventricular size has been established
in the dog.13'14,17,18Asymmetry in ventricular sizeis often normal
in dogs.
Occipital dysplasia
Occipital dysplasiais the dorsal extension of the foramen magnum;
it has been related to clinical signs of neurologic diseasete" and is
usually identified in miniature and toy breeds.tnForamen magnum
size and shape are best evaluated in the rostrodorsal-caudoventral
skull radiograph. The anesthetizedpatient is placed in dorsal re-
cumbenry with the neck flexed so that the nose is angled toward
the sternum. The central x-ray beam is directed between the eyes
and exits through the foramen magnum. The beam is angled 25 to
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

graphic skeletal changes in cats with MPS VI include epiphyseal

dysplasia,generalizedosteoporosis,pectus excavatum,and vertebral
and skull changes.'ze Specific skull changes seen on radiographs
include shortened nasal conchae, apiasia and hypoplasia of the
frontal and sphenoid sinuses, and shortened dimensions to the
incisive and maxillary bones.2eAnother form of mucopolysacchar-
idosis, MPS I, has been documented in the domestic shorthaired
cat3owith radiographic skeletalchangesthat are similar to those in
MPS VI; however, the faciai dysmorphia may not be as pronounced
as it is in the Siamese.3t

Figure 7-3. Lateralradiograph
of a 1-year-old
maleChihuahua with severe
hydrocephalus.Notethe homogeneousappearanceof the calvaria
caused by
a lossof the normalconvolutional (Courtesy
skullmarkings. of Dr.Wendy
Myer,OhioStateUniversity,
Columbus,Ohio.)
Figure 7-4 representsboth the normal and the abnormal appear-
ance of the foramen magnum as seen on the rostrodorsal-caudo-
ventral skuil radiograph. Studies suggestthat occipital dysplasia is
common in small-breed dogs, may not causeneurologic signs, and
is a normal morphologic variation in brachycephalicdogs." tt
Temporomandibular joint dysplasia
Open-mouth jaw locking is the clinical sign associatedwith tempo-
romandibuiar joint dysplasia.This congenital condition is uncom-
mon; it is most frequently reported in the Bassethound, but has
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
the zygomatic arch. Physical entrapment usually occurs on the
contralateral side from the joint with the most severe dysplastic
changes(Fig. 7-5). Yawning often precipitates jaw locking when it
results in extreme opening of the mouth.t6
Mucopolysaccharidosis
Mucopolysaccharidosesare a group of hereditary disorders of lyso-
somal storage, which occur in humans, dogs, cattle, and cats.27
Mucopolysaccharidosis VI (MPS VI) is an autosomal recessive
lysosomalstoragediseaserecognizedin Siamesecats.'?8 Radio-
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
hyperparathyroidism. This results in excessivesynthesis and secre-
tion of parathltoid hormone, which leads to hypercalcemia and
subsequent bone resorption.32Secondary hyperparathyroidism,
which includes renal and nutritional secondary hyperparathyroid-
ism, is subsequent to nonendocrine alterations in calcium and
phosphorushomeostasisthat lead to increasedlevelsofparathyroid
hormone and ultimate bone resorption.32
An early radiographicsign ofhyperparathyroidism(primary and
secondary) is loss of the lamina dura. Lamina dura loss and
demineralization of the mandible and maxilla result in a floating
appearance to the teeth; subsequent fibrous osteodystrophy can
lead to thickening of the affected part of the skull (Fig. 7=6).
Level of cortical thinning and degree of overall osteolysis and
osteomalaciadependon duration and severityofthe disorder;they
also determine the degreeof tooth displacement.Becauseyoung
animals are growing and have rapid skeletal turnover, they are
more severelyaffected than older animals (Fig. 7-7).
I Neoplastic abnormalities
Nasal tumors
Tumors of the nasal cavity in dogs and cats account for approxi-
mately 1% to 2o/oof a\I neopiasmi. .t Thesetumors occur in older
dogs and cats; about two thirds of al1 tumors are carctnomas
(adenocarcinoma,squamous cell carcinoma, undifferentiated carci-
noma), and the other one third are sarcomas(fibrosarcoma, chon-
drosarcoma, osteosarcoma, undifferentiated sarcoma). Intranasal
Iymphoma can also occur, with a higher prevalence in cats.36-3s
Tumors of the nasal cavity are locally invasive, and external beam

rlrrllgllrr:iiiigll
i119r:ilr9rrr::11
$ll:::11@lllr.]:r@;
llr.ii@l
'{-'s lifflr]:i
w' R' q;
*lt:ilG&lt:tiBlRtlBtl:llgtltl:t!!$l
rlll9lll:ll:ll3lll:::lllallltllal:lll.r.:
cutr:3@;1eu:iillsu.iil3ut-,iiil

Figure 74. Rostrodorsal-caudoventral

obliqueradiographof the sku I in three small-breeddogs. Note the appearanceof the foramen magnumjarows indicate
the dorsalextent.A, Normalforamenmagnum.B, Moderateoccipitaldysplasia.C, Severeoccipitaldysplasia.(Courtesyof Dr.Wendy Myer, Ohio State University,
C o l u m b u sO
. hio.)
74 AXIALSKELETON

ffi#ry

riBll
gll rlg
lll.il@llill:r,i;
:;5::;;::-*1 l$lr.:c
lliiriirilrr:

;.,".; ..t:,"g.#;
lll!)),,-,ii:1;llll':

Figure 7-5, Open-mouth,left dorsal-rightventral(A);open-mouth,right dorsal-leftventral /8/; closed-mouth,ventrodorsal/CJ;and open-mouth,ventrodorsal

/D/ radiographsof the temporomandibular female Gordonsetter with a historyof chronicintermittentjaw locking.Thereis subluxation
joints (TMJ)of a 2-year-old
of the right TMJ /A/ comparedwith the more normalappearanceof the left TMJ iBi. Radiographs were made after the jaw was locked.Note the differencein the
relationshipof the coronoidprocessof the mandibleand the zygomaticarch on the closed-mouth,ventrodorsalradiograph(C/ comparedwith the open-mouth,
ventrodorsalview (D)after the jaw has been lockedin the open position.When the jaw is ocked,the coronoidprocessshifts laterallyand is ln contactwith the
zygomaticarch(D, arrowheadsl.(Courtesyof Dr. Wendy Myer, Ohio State University,Columbus,Ohio.)
 The C rani aland N asalC avi ti es-C ani ne
and Feline 75

Figure 7-6. Lateralskullradiograph

oI a 12-year-old
femaieScottish
terrier
with primaryhyperparathyroidism
andseverefibrousosteodystrophycausing
thickening
of the maxilla
anddisplacementof teeth.Notetheabsenceof the
laminaduraaroundthe toothroots.icourtesyof Dr.WendyMyer,OhioState
University,
Columbus,Ohio.)

radiotherapy is the current treatment of choice. Unfortunately,

diagnosis of these tumors often occurs late in the course of disease,
resulting in a poor prognosis for outcome in many patients.
Nasal cavity tumors have an aggressiveradiographic appearance,
with bony invasion and loss of conchal detail being common
radiographic features.3sa0 Tirmors are often unilateral, have an
increased soft-tissue opacity with underlying conchae destruction,
and reveal an increasedopacity within the ipsilateral frontal sinus38,
a0+2;the latter radiographic sign usually indicates obstructive sinu-
sitis but occasionallyresults from tumor extension.The most useful
radiographic views for evaluating nasal diseaseinclude the intraoral
Figure 7-8- Open-mouth, ventrodorsalradiograph of the nasalcavityof a 7
year-oid
femaleChowChowwitha 1 weekhistory of left-sided
facialswelling
andnasaldischarge. Notethe increased opacity,lossof conchal detail,and
bonydestruction of the cribriformplateof the left nasalpassage.Theright
sideof the cribriformplateis intact(arrowhead).Unilateralinvolvement and
bonydestruction are suggestive of a nasalcavitytumor.The diagnosis of
adenocarctnoma wasmadehistoloqicallv.
dorsoventral and/or the open-mouth ventrodorsal view for detailed
evaluation of the nasal cavity without superimposition of the man-
dibie (Fig. 7-8). The open-mouth ventrodorsal view is better for
cribriform plate assessmentbecauseradiographic film cannot phys-
ically be positioned to include the cribriform plate in the intraoral
view. The cribriform plate is representedby a "V"-shaped to "C,'-
shaped bony opacity on radiographs, varying according to skull
shape (dolichocephalic versusmesaticephalicand brachycephalic).a3
Evaluation of the cribriform plate is important becausenasal tu-
mors often originate from the ethmoid conchae and cribriform
plate,aaand bony lysis detected on radiographs indicates potential
tumor extension into the brain (see Fig. 7-8). The rostrocaudal
frontal sinus projection is necessaryfor evaluation of individual
frontal sinuses(Fig. 7-9). General anesthesiais an absolute require-
ment for achieving accuratepositioning, and it facilitates evaluation
and comparison of the complex nasal passages.Illustrated tech-
niques for obtaining radiographic views of the nasal cavity and
paranasalsinusescan be found elsewhere.as

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

The radiographic appearanceof nasal tumors varies with histo-

logic tlpe and duration. More aggressivetumors and those with a
prolonged duration appear destructive and less confined radio-
graphically, often exhibiting an external soft-tissue mass that repre-
sents tumor extension through overlying bone. Conchae destruc-
tion and deviation, and destruction of the bony nasal septum are
apparent on radiographs. Radiographic evidence of bony destruc-
tion is an important prognostic sign; aggressivebony lysis is associ-
ated with a poor outcome.4r'42'46'47 Lessaggressive tumors and ones
that present earlier are difficult to differentiate from rhinitis on
radiographs."
CT of the nasal passageis superior to routine radiography for
accuratetumor staging and is useful in the differentiation of infec-
tious rhinitis from neoplasia.a8 sr Most institutions and practices
that treat nasal tumors with radiotherapy use CT-based computer-
ized treatment planning systems, which provide improved dose
distribution acrossthe tumor volume and probable improved sur-
vival.t2

Mandibular and maxillary tumors

Tumors of the oral cavity account for approximately 60/o of all
canine cancers and.3o/oof feline cancers.s3'sa Squamous cell carci-
noma tumors commonly affect the mandibie or maxilla in the dog Figure 7-1O. Intraoralventrodorsalradiographof a 12-year-olddomestic
medium-haircat with a swellingof the left mandible.Note the mottled expan-
and cal. Fibrosarcoma, malignant melanoma, and tumors of the
si on of the l eft rostralmandi bl e.The di aonosi sof souamousc el l c arc i noma
periodontal ligament (epulis) are common in the dog, but rarely w as madehi stol ogi cal l y.
occur in cats.ss
In the dog, the rostral mandible is a site of predilection for oral
squamous cell carcinoma. This tumor has variable bony lysis, and
regional or distant metastasisis rate.s6Oral fibrosarcoma tumors Multilobular osteoehondrosarcoma
in dogs can affect the maxilla or mandible with a predilection for Muitilobular osteochondrosarcoma (MLO) is a rare tumor that
the oalate.56In a recent report of maxillary and incisive tumors in arises from the skull of dogs. Other names used to describe this
dogi, 8zoloof squamous ce^Ilcarcinomas and 78o/oof fibrosarcomas tumor include chondroma rodens and multilobular osteoma.These
demonstrated bone involvement radiographically.aTOften, oral fi- tumors often arise from the temporo-occipital area of the skull,
brosarcoma appears benign histologically, but biologic activity is although involvement of the orbit, maxilla, mandible, tyrnpanic
aggressive.These tumors, often found in the maxilla and mandible bulla, and zygomatic arch has been reported.uatt These tumors
of large-breed dogs and commonly in Golden retrievers, are called have characteristic radiographic features. The margins of MLO are
histologically low-grade yet biologically high-grade fibrosarcoma. well defined, and there is limited lysis of adjacent bone.73The
Bony lysis is a common feature.sTDogs with oral fibrosarcoma central core of the tumor comprises a coarse, granular mineral
have a lower median survival as compared with those with soft- opacity throughout (Fig. 7-12). Dogs with MLO are older, large-
tissue sarcomas at other sites.s8In contrast, malignant melanoma breed dogs.67'73
Approximately 50oloof dogs experiencelocal recur-
tends to occur in smaller-breed dogs, commonly metastasizesto
regional lymph nodes and lungs, and shows variable bony lysis
radiographically.t6 Squamous cell carcinoma in cats affects the
mandible or maxilla, causing expansile,lytic changesto bone (Fig.
7-10). Unlike squamouscell carcinoma in the dog, these tumors
have a poor prognosis in the feline species.tu
The epulides of periodontal origin have been divided by patholo-
gists into three categories:fibromatous epulis, ossi$ring epulis, and
acanthomatous epulis.seFibromatous and ossifring epulides are
similar benign growths cured by surgical excision; the distinctive
feature of ossif ing epulis is the histologically large segments of
osteoid matrix.ssThe predominant feature of acanthomatous epulis
is the sheets of acanthomatous epithelial tissue noted histologi-
callytt and the local invasion, which often causesbony destruction
on radiographs.Thesetumors are radiosensitive.6o'6'
Tumors originating fiom dental laminar epithelium in dogs and
cats include ameloblastoma,odontoma (Fig. 7-11), and inductive
fibroameloblastoma. Although rare, ameloblastoma is the most
common tumor of dental origin in the dog and presents as a
slowly growing, expansile mass.55Inductive fibroameloblastoma is
a rare tumor of the rostral maxilla found in young cats.ss'62
Tieatment options for oral tumors consist of surgical excision
alone, radiotherapy alone, or a combination of surgery and radio-
therapy.sr60,61,6365In a study of 100 dogs with oral tumors treated
by mandibulectomy or maxillectomy, excellent survival rates were Figure 7-11- Intraoralventrodorsalradiographof a 3-month-oldmale collie
w i th a compl exodontoma.The i rregul arlmargi
y heterogeneousmi
nated, l y ner-
achieved for carcinomas, acanthomatous epulides, and squamous alizedmass hascauseddestructionof the rostralmandibleand displacedteeth.
cell carcinomas, with poorer outcomes noted for sarcomas (fibro- The soft tissue componentof the mass extendsacrossthe midline. (courtesy
sarcoma,osteosarcoma,and malignant melanoma).6' of Dr. Wendy Myer, Ohio State University,Columbus,Ohio).

rence after treatment (surgical excision alone, or surgery and radio-
therapy), and approximately half develop metastatic disease.67, 70'73
CT is superior for the detection of cranial vault invasion, which
was a common feature in five of sevenpatients recentiy described.t'
Other tumors of the cranium
Other primary tumors of the cranium include osteosarcoma,oste-
oma, and osteochondroma.Osteosarcomais the most common
primary bone tumor, with 10% to l5o/o arising from the skull.
Distribution of canine skull osteosarcomain one reDort included
cranial vault tn 37o/o,facial bone in 360/o,and mandible in 27o/oof
patients.TsOsteosarcomasarising from the cranial vault do not
resemble those from the appendicular skeleton or other skull sites.
Osteosarcomasof the cranium tend to be osteoblastic,have weli-
defined borders, and contain granular areasof calcification.T6Oste-
oma is a slow-growing, benign tumor that has a smooth, well-
defined border on radiographs(Fig 7-13). Thesetumors can arise
from the mandible, cranial vault, or sinuses.T6
Tumors of the brain are best identified with either CT or MR
imaging. One brain tumor in which radiographic changesmay be
noted on routine skull radiographs is feline meningioma (Fig.
7-14). These tumors may calcify and causesclerosisand/or lysis of
the adjacent bony calvaria.tt
I lnfectious disorders
Nasal aspergillosis
Nasai aspergillosisis a destructive rhinitis involving the nasal cavity
and paranasal sinuses of the dog; it affects younger (less than 4
The C rani aland N asalC avi ti es-C ani ne
and Feline 77
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.)
years of age), nonbrachycephalic breeds more frequently than it
does other breeds.'8'?e Aspergillus species (primarily Aspergillus
fumigatus) are common saprophltic fungal organisms found in the
environment.T8Destructive rhinitis caused by other fungal agents,
such as Penicillium species,is less common.7s,80 Nasal blastomycosis
can occur in endemic areas.The most common radiographic ap-
pearanceof nasal aspergillosisincludes lysis of conchaewith punc-
tate lucenciesof bone (Fig. 7-15).ao'o8r Increasedlocalizedsoft-
tissue opacity of the nasal cavity is also seen, but frontal sinus
involvement is variable and consistsof sinus oDacitv with or with-
out mottled bony thickening.4O, 7e'sr Bony nasal septum erosion
or deviation is uncommon except in cases of advanced disease.
Cryptococcusneoformans,a fungai infection more commonly seen
in cats, can infect the nasal passages,but generally causesa non-
destructive hyperplastic rhinitis (Fig. 7-16).u, s
Destructive rhinitis secondary to fungal diseasecan be difficuit
to differentiate from neoplasia. Both diseasescauseloss of conchal
detail, but soft-tissue swelling, bony invasion, and ipsilateral frontal
sinus opacity are more common featues of nasalcavity neoplasia.ro'tt
Regardlessof the radiographic presentation, a biopsy sample for
histopathologic evaluation is necessaryfor diagnosis.
Nasal rhinitis and foreign bodies
Rhinitis secondary to bacterial infection, or corticosteroid-respon-
sive rhinitis with lymphoplasmacytic infiltrates, can have a variable
radiographic appearancein dogs and cats. Depending on the chro-
nicity and severity of rhinitis, there will be evidence of destruction
of conchae and of bony erosion.3sChronic rhinitis and sinusitis in
cats are common sequelaeto viral upper respiratory tract disease.
78 A X I A LS K E LE T O N
Radiographic changes can range from an increased opacity of
the nasal cavity and frontal sinuses to conchae and vomer bone
destruction (Fig.7-17).38'o' In five dogs with lymphoplasmacytic
rhinitis, the radiographic appearancevaried from increasedopacity
without bony destruction to nasal conchae and vomer bone lysis.8s
Destruction of conchae is not a reliable radiographic sign for
differentiating destructive rhinitis secondaryto aspergillosisor neo-
olasiafrom other forms of rhinitis.r8'81 86
Intranasal foreign bodies can occur in dogs, and foreign plant
matter is common in certain environments, for example, grass
lawns in California. Dogs present with an acute onset of sneezing
and pawing at the nose, and they often have a unilateral nasal
discharge.'a" Radiographycan identifu radiopaqueforeign bodies
(Fig. 7-18). Localization of radiolucent foreign bodies may be
possiblebecauseof the presenceof inflammation and mucopuru-
lent material, which appear as an increasedsoft-tissueopacity on
radiographic images.
Figure 7-14. Rostrodorsal-caudoventral
year-ol ddomesti cshort-haicat
thi ckeni ng(hyperostosiof
Figure 7-13. A, Ventrodorsalradiographof
a 9-year-oldfemale mixed-breeddog with an
osteomaof the left zygomaticarch. B, Ventro-
dorsalradographof an aged cat iwith an oste-
oma of the rostral portion of the right zygo-
mati c arch. N ote the smooth , w el l -defi ned
margi nsof thesetumorsand th e l ac kof bony
destructi on, w hi ch suggesta b eni gneti ol ogy .
(Courtesyof Dr. Wendy Myer, Ohio State Uni-
versi ty,C ol umbus,Ohi o.)
otitis
Radiographs are an integral part of the diagnostic work-up of a
dog or cat presenting with ear disease.Radiographic evaluation of
the external and middle ear is possible for evaluation of otitis
externa and media. However, diagnosis of otitis interna is based on
clinical signs because it does not reliabiy produce radiographic
changes.8s A ventrodorsal radiograph is best suited for evaluation
of the external ear canal where stenosisand/or mineralization can
be identified, indicating otitis externa (Fig. 7-19). Otitis media is
often secondary to chronic otitis externa. Evaluation of tympanic
bullae for the presence of increased opacity or thickening of the
osseousbulla, indicating otitis media, is best seen on the lateral
oblique and open-mouth projections(Fig.7-20). Otitis media can
be unilateial; when this occurs, the diagnosis is simplified by an
internal comparison between the normally air-filled tympanic bulla
and the affectedside (seeFig.7-20). In advanceddisease,exuberant
obliqueradiographof the skull of a 12-
r w i th a l eft cerebralmeni ngi omaN. ote the bony
s) the l eft si deof the cal vari um.
 The C rani aland N asalC avi ti es-C ani ne
and Feline 79

?,:,;i
:'.:::::.,,:
tlllli::

Figure 7-15. Open-mouth,ventrodorsaIAl and rostrocaudal_frontal sinus

/B/ radiographs of a 9-year-old
female Labradorretrieverwith a 3-monthhistory
of nasaldi scharge. N otethe destructi on
of the nasalconchaei n the mi dporti on
of the left nasalcavity 1Aland the increasedopacityto the left, frontal sinus
(B). There is also evidenceof frontal-boneirregularity,indicatingdestructive
sinusitis/B/. Destructiverhinitissecondaryto Aspergillusfumigatuswas diag-
nosedby cul ture.

Figure 7-16. Intraoral,dorsoventrairadiographof a 4-year-olddomestlc Figure 7-17, Open-mouth,ventrodorsalradiographof a 13-year-oldcas-

s h o r t - h a icra t w i t h a h isto r yo f n a sa ld isch a r g eNo
. te th e in cr eased
opaci tyto trated maledomesticshort-haircat with a 4-week historyof primarilyleft-sided
the right nasalcavitywithout loss of conchaldelail.Crvptococcusneoformans nasaldi schargeand anorexi a.N ote the di ffusei ncreasei n o D ac i tvof the l eft
wa s d i a g n o s e d b y c u l tu r e . nasalcavi tyw i th l oss of conchaldetai l .S everesubacutep y ogranul omatous
rhinitis secondaryto Pasteurellamultocidawas diagnosedfoliowing nasal
curettageand culture. (Courtesyof Dr. Wendy Myer, Ohio State University,
C ol umbus.Ohi o.)
80 AXIALSKELETON

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
temporomandibular joint. Positioning is crucial when radiography
of the bullae is performed; general anesthesia facilitates proper
positioning and allows personnei to vacate the room during radio-
graphic exposure. A review of imaging techniques for middle ear
diseasecan be found elsewhete.8e'eo
When radiographic and surgical findings of otitis media were
compared, all cases with abnormal radiographic findings were
confirmed surgically.However, 25o/oof patients with normal radio-
graphs of the middle ear were abnormal at surgery.elCT is a more
sensitive test for evaluation of otitis media,e'?but proper imaging
technique is necessaryto avoid artifactual wall thickening of the
bulla on CT images."r
Feline nasopharyngealpollps are non-neoplastic growths origi-
nating from the mucous membrane of the auditory tube or middle
ear.nnNasopharyngeal polyps generally occur in younger cats and
can extend into the external ear canal, the osseousbulla, or the
nasopharynx. Cats may present with signs of middle ear disease'
rhinitis, or upper airway diseasesecondary to the space-occupying
pol1p. Signs of otitis media (increased soft-tissue opacity of the
affecledbulla) or nasopharyngealobstruction (Fig.7-21) may be
noted on radiographs. In a study of 31 cats with nasopharyngeal
polyps, a radiographic diagnosis of otitis media was made in 26
cats, and nasopharyngealmasseswere detected in 30 cats.es
Ear canal tumors can occur in dogs and cats. Most often, these
soft-tissueneoplasmsare squamous cell carcinoma or mucinous
gland adenocarcinoma. These masses obliterate the external ear
canal and can cause aggressivebony lysis of the adjacent calvaria
and osseousbdla (Frg.7-22).
Periapical (tooth root) abscess
Periapical infection has a tlpical radiographic appearance of a
radiolucent halo around the affected tooth root with destruction
of alveolar bone (Fig. 7-23). Other radiographic signs seen with
periapical abscessinclude widening of the periodontal spacesur-
rounding the apex, bone lysis or sclerosisadjacent to the apex, loss
of the lamina dura, and resorption of the tooth root. Periapical
infections are common in older animals and may be secondary to
periodontal disease or fracture of the affected tooth. In dogs,
infections of the fourth maxillary premolar (carnassialtooth) often
result in an external fistulous draining tract below the eye.
Dental radiographs can be obtained using conventional x-ray
equipment and film-screen combinations, which consist of open-
mouth oblique views of the dental arcades.A dental x-ray machine
provides enhanced flexibility in adjustment of focal film distance,
angulation, and collimation, and it enablesthe use, with improved
accuracy,of small, intraoral dental film.u Since the recognition of

Figurc 7-19. Ventrodorsalradiographof an 11-year-old Goldenretrieverwith a

historyof chronicear disease.Note the narrowedexternalear canals(arrowheads),
consistentwith a diagnosisof otitls externa.

Figure 7-2O. Tympanicbullaradiographs
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.
the American Veterinary Dental Collegeby the American Veterinary
Medical Associationin 1988,there has been an increasednumber
of specialists in veterinary dentistry. It is common practice for
these dentists to perform endodontal and periodontal procedures
to treat dental diseasein dogs and cats.4
I Traumatic injuries
Temporomandibular joint (TMf) luxation can occur in both dogs
and cats after external trauma. In the cat, TM| luxation often
occurs after the cat has jumped from a height, and in both dogs
and cats, dislocation can occur secondaryto being hit by a car."o
The TMJ is capable of luxation without fracture because it has
The C rani aland N asalC avi ti es-C ani ne
an d Feline 8l
of a 6-year-old female domesticshort-haircat w;th chronicotitis externaand media.Comparethe normalleft bulia(air-
(Courtesyof Dr. Wendy Myer, Ohio State Universitv,Columbus.Ohio.)
considerable lateral sliding movement, and the sl.nchondrosis of
the mandibular symphysis allows independent movement of the
mandibular rami.eT Dislocation of the TMI tends to be in the
rostrodorsal direction (Fig. 7-2a), as ventrocaudal luxation is pre-
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
one side, and display excessivesalivation.e6, et Luxation is most
often unilateral; it may occur alone or with concomitant fractures
of the retroarticular process,mandibular fossa,and zygomatic pro-
cessof the squamoustemporal bone, or with the condyloid process
of the mandible.e6
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
same views are useful in the dog. A sagittal oblique radiograph, in
which the nose is elevated with a foam wedge so that the head is
at a 20-degree angle to the cassettefrom a lateral position, is
advocatedin dogs as an alternative to lateral oblique views.n5
I Miscellaneous diseases
Craniomandibular osteopathy
Craniomandibular osteopathy (CMO) is a proliferative bone dis-
easethat occurs mainly in young West Highland White, Scottish,
Cairn, Boston, and other terriersl it is occasionallvseen in nonter-
rier breeds such as the Labrador retriever and the Doberman
pinscher. There is a known autosomal recessiveinheritance in West
Highiand White terriers.%CMO is usually seen in young dogs aged
3 to 8 months; affected dogs have mandibular swelling, prehension
difficulties, pain on opening the mouth or with mastication, py-
rexia, or combinationsof theseclinical sisns.3r,ee
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
proliferation is somewhat irregular and often bilateral and may be
asymmetrical, although unilateral presentation can occur. Bony
proliferation can involve the temporomandibular ioint and can
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
Figure 7-26. Obliqueradiograph of a 14-year-old,
of the rostralmandible
of the
mixed-breed dog with severedentaldisease.Note the irregularity
teeth Also notethe
alveolar crestbetweenthe secondand thirdpremolar
lysisof the caudalrootof the first premolarandthe rostralrootof the third
premolal changesconsistentwithdentalrootcaries.
radiographic findings. Bone biopsy is helpful in nonterrier breeds
with unilateral involvement. Concurrent metaphyseal long-bone
changessimilar to hypertrophic osteodystrophy have been seen in
dogs with CMO, but this is uncommon.3' CMO is a self-limiting
diseasewith unknown etiology. Bony proliferation generally ceases
with skeletalmaturation.
Periodontal disease
The structures that support the teeth include the cementum, the
periodontal ligament, the alveolar bone, and the gingiva. Periodon-
ial disease involves both hard tissue (cementum, alveolar bone)
and soft tissue (periodontal ligament, gingiva) that surrounds the
teeth; it commonly affects dogs and cats.a Gingival recession or
hyperplasia and bony resorption in periodontal disease lead to
oiti-it. loss of tooth support. Although radiography provides little
information about gingival tissues, it is an important part of the
evaluation of bony structures in periodontal disease.
Early radiographicsignsofperiodontal diseaseinclude an irregu-
lar surface und botte loss in the alveolar crest. The lamina dura
may be ill defined or may lack continuity.a As the disease pro-
g.ei..r, horizontal bone loss of a group of teeth occurs so that
ilveolar bone resorption developsaway from the tooth crown, thus
exposing tooth roots. Widening of the periodontal space is also
seen. Alveolar bone recession exPosesroot surfaces, which can
lead to root caries and root resorption, seen radiographically as
radiolucentdefects(Fig. 7-26).\ao
References
1 Miller ME, Evans HE: Miller's Anatomy of the Dog, 3rd ed. Philadelphia, WB
Sa u n d e rs.1 9 9 3 .
2. Hawey CE: The nasal septum ofthe dog: Is it visible radiographically? Vet Radiol
20:88 90, 1979.
3. Morgan lP, Miyabayashi T: Dental radiology: Aging changesin permanent teeth
ofbeagle dogs. J Small Anim Pract 32:11-18, 1991.
4. Mulligan TW, Aller MS, Williams CA: Atlas of Canine and Feline Dental Radiog
raphy. Trenton, Veterinary Learning Systems, 1998.
5. San Roman F, Llorens MP, Pena M! et al: Dental radiography in the dog with a
conventional x-ray device. Vet Radiol 31:235-238, 1990'
6. Zontine Wl: Dental radiographic technique and interpretation. Vet Clin North
Am 4 :7 4 1 -7 6 2 ,1 9 7 4 .
7. Zontine WJ: Canine dental radiology: Radiographic technique, development, and
anatomy ofthe teeth. J Am Vet Radiol Soc 16i75 82,1975-
8. Hoskins JD: Congenital defects of the dog. In Ettinger Sf, Feldman EC (eds):
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.
10. Krum S, Johnson K, Wilson J: Hydrocephalus associatedwith the noneffusive
form of feline infectious peritonitis. J Am Vet Med Assoc 167:745, 1975.
11. Shell LG: Congenital hydrocephalus. Feline Pract 24:I0-ll, 1996.
12. Hoerlein BF: Canine Neurology. Philadelphia, WB Saunders, 1978.
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.
16. Vullo T, Korenman E, Manzo RP, et al: Diagnosis of cerebral ventriculomegaly in
normal adult beaglesusing quantitative MRI. Vet Radiol llltrasound 38:277-2.81,1997.
17. Hudson JA, Cartee RE, Simpson ST, et al: llltrasonographic anatomy of the
canine brain. Vet Radiol 30:13-21, 1989.
18. Hudson ]A, Simpson ST, Cox NR, et al; Ultrasonographic examination of the
normal canine neonatal brain. Vet Radiol (Jltrasound 32:50-59, l99L
19. Bardens jW: Congenital malformation of the foramen magnum in dogs.
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
101520,1974.
22. Ticer lW: Radiographic Technique in Veterinary Practice. Philadelphia, WB
Saunders, 1984.
23. Watson AG: The phylogeny and development of the occipito-atlas-axis complex
in the dog. Ithaca, NY, Cornell University, 1981.
24. Wright JA: A study of the radiographic anatomy of the foramen magnum in
dogs. J Small Anim Pract 20:501, 1979.
25. Simoens R Poels R Lauwers H: Morphometric analysis of the foranen magnum
in Pekingesedogs. Am J Vet Res 55:34-39, 1994.
26. Robbins G, Grandage J: Temporomandibular joint dysplasia and oPen-mouth
jaw locking in the dog. I Am Vet Med Assoc 171:1072-1076, 1977.
27. Cowell KR, lezyk PR Haskins ME, et al: Mucopolysaccharidosis in a cat. I Am
Vet Med Assoc 1.69:334-339,1976.
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
29. Konde LJ, Thrall MA, Gasper P, et al: Radiographically visualized skeletal changes
associatedwith mucopolysaccharidosisVI in cats. Vet Radiol 28:223-228,1,987.
30. Haskins ME, Aguirre GD, Iezyk PF, et al: The pathology of the feline model of
mucopolysaccharidosisL Am J Parhol 112:27-36,1983.
31. Johnson KA, Watson ADJ: Skeletal diseases.In Ettinger Sl, Feldman EC (eds):
Textbook of Veterinary Internal Medicine: Diseases of the Dog and Cat, 5th ed.
Philadelphia, WB Saunders,2000.
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.
Philadelphia, WB Saunders,2000.
33. Brodey RS: Canine and feline neoplasia. Adv Vet Sci Comp Med 14:309-354,
1970.
34. Madewell BR, Priester WA, Gillette EL, et al: Neoplasms of the nasal passages
and paranasal sinuses in domesticated animals as reported by 13 veterinary colleges.
Am T Vet Res 37:851-856,1976.
35. Engle GC, Brodey RS: A retrospective study of 395 feline neoplasms. I Am Anim
Hosp Assoc 5:21-31, 1969.
36. Allen HS, Broussard l, Noone K: Nasopharlngeal diseasesin cats: A retrospective
study of 53 cases(1991-1998). J An Anim Hosp Assoc 35:457461, 1999.
37. Evans SM, Hendrick MJ: Radiotherapy of feline nasal tumors: A retrosPective
study ofnine cases.Vet Radiol 30:128-132,1989.
38. O'Brien RT, Evans SM, Wortman JA, et al: Radiographic findings in cats with
intranasal neoplasia or chronic rhinitis: 29 cases(1982-1988). J Am Vet Med Assoc
208:385 389, 1996.
39. Harvey CE, Biery DN, Morello J, et al: Chronic nasal disease in the dog: Its
radiographic diagnosis. Vet Radiol 20:91-98, 1.979.
40. Russo M, Lamb MA, Jakovljevic S: Distinguishing rhinitis and nasal neoplasia by
radiography.Vet Radiol Ultrasound 41:118-124,2000.

,11. Morris JS, Dunn KJ, Dobson JM, et al: Radiological assessmentof severity of
canine nasal tumours and relationship with survival. J Small Anim Pnct 37iI-6, 1996.
42. Morgan IR Suter PR O'Brien TR, et al: Tumors in the nasal cavity of the dog: A
radiographic study. I Am Vet Radiol Soc 13:18-26,1972.
43. Schwarz I Sullivan M, Hafiung K: Radiographic anatony of the cribriform plate
(lanina cribrosa). Vet Radiol Ultrasound 41:220-225, 2000-
44. Bright RM, Bojrab MJ: Intranasal neoplasia in the dog and cat. J Am Anim
Hosp Assoc 12:806,1976.
45. Morgan JP, Silverman S: Techniques of Veterinary Radiography, 4th ed. Ames,
Iowa, Iowa State University Press, 1984.
46. Cox NR, Brawner WR, Powers RD, et al: Tumors of the nose and paranasal
sinusesin cats:32 caseswith comparison to a national database(1977-1987).] Am
Anim Hosp Assoc 27:339-347. 1991.
47. Frew DG, Dobson JM: Radiological assessmentof50 casesofincisive or maxillary
neoplasiain the dog. I Small Anim Pract 33;11-18, 1992.
48. Burk RL: Computed tomographic imaging of nasal disease in 100 dogs. Vet
Radiol Ultrasound 33:177-180, 1992.
49. Codner EC, Lurus AG, Miller lB, et al: Comparison of computed tomography
with radiography as a noninvasive diagnostic technique for chronic nasal disease in
dogs.I Am Vet Med Assoc 202:1106-1110,1993.
50. Park RD, Beck ER, Lecouteur RA: Comparison of computed tomography and
radiography for detecting changes induced by malignant nasal neoplasia in dogs. J
-{m Vet Med Assoc 201t1720-1.724,1992.
51. Thrall DE, Robertson ID, Mcleod DA, et al: A comparison of radiographic and
computed tomographic findings in 3t dogs with malignant nasal cavity tumors. Vet
Radiol 30:59-66, 1989.
52. McEntee MC, Page RL, Heidner GL, et al: A retrospective stvdy of 27 dogs with
intranasal neoplasms treated with cobalt radiation. Vet Radiol Ultrasound 32:135-
1 3 9 ,1 9 9 1 .
53. Hoyt RF, Withrow Sl: Oral malignancy in the dog. J Am Aaim Hosp Assoc
.10:83-92,1984.
54. Stebbins KE, Morse CC, Goldschmidt MH: Feline oral neoplasia: A ten-year
suwey.Vet Pathol 26:121-128.1989.
55. Dubielzig RR: Proliferative dental and gingival diseasesof dogs and cats. J Am
,{lim Hosp Assoc 18:577-584,1982.
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,
phia, WB Saunders, 1996, pp 227-240.
57. Ciekot PA, Powers BE, Withrow SJ,et al: Histologically low-grade, yet biologically
high-grade, fibrosarcomas of the mandible and maxilla in dogs: 25 cases(1982-1991).
l Am Vet Med Assoc 204:610-615,1994.
58. Forrest LJ, Chun R, Adams WM, et al: Postoperativeradiotherapy for canine soft
tissue sarcoma. J Vet Intern Med 14:578-582, 2000.
59. Dubielzig RR, Goldschmidt MH, Brodey RS: The nomenclature of periodontal
epulides in dogs. Vet Pathol 16:209-214,7979.
60. Langham RF, MostoskF UV, Schirmer RG: X-ray therapy of selectedodontogenic
neoplasms in the dog. J Am Vet Med Assoc 170:820-822, 1977.
61. Thrall DE: Orthovoltage radiotherapy of acanthomatous epulides in 39 dogs. J
-Lm Vet Med Assoc 184:826-829, 1984.
62. Dubielzig RR, Adams WM, Brodey RS: Inductive fibroameloblastoma, an unusual
dental tumor ofyoung cats.J Am Vet Med Assoc 174:720-722,1979.
63. White RAS: Mandibulectomy and maxillectomy in the dog: Long term survival
in 100 cases.I Small Anim Pract 32:69-74,199I.
61. Bateman KE, Catton PA, Pennock PW, et al: 0,7 21 Radiation therapy for the
ireatment of canine oral melanoma. I Vet Intem Med, 8:267-272. 1994.
65. Blackwood L, Dobson lM: Radiotherapy of oral malignant melanomas in dogs.
T -\m Vet Med Assoc209:98-102,1996.
66. Pletcher JM, Koch SA, Stedhem MA: Orbital chondroma rodens in a dog. J Am
\et Med Assoc 175:\87,1979.
67, Dernell WS, Straw RC, Cooper MF, et al; Multilobular osteochondrosarcoma in
39 dogs: 1979-1993.J Am Anim Hosp Assoc34:11-18, 1998.
68. Zaki FA, Liu S-K, Kay Wl: Calcitling aponeurotic fibroma in a dog. I Am Vet
\led Assoc 166:384-387,I975.
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.
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-
-r62,1983.
The C rani aland N asalC avi ti es-C ani ne
and Feline 85
71. GroffJM, Murphy Cl, Pool RR, et al: Orbital multilobular tumour of bone in a
dog. J Small Anim Pnct 33:597-600, 1992.
72. McCalla TL, Moore CR Turk J, et al: Multilobular osteosarcomaof mandible and
orbit in a dog. Vet Pathol 26:92-94, 1989.
73. Straw RC, Lecouteur RA, Powers BE, et al: Multilobular osteochondrosarcoma
ofthe canine skull: 16 cases(1978-198S).J Am Vet Med Assoc 195:1764-1769,1989.
74. Hathcock JT, Newton lC: Computed tomographic characteristics of multilobular
of bone involving the cranium in 7 dogs and zygomatic arch in 2 dogs. Vet
!u1to1
Radiol Ultrasound 4t:214-217, 2000.
75. Hardy WD, Brodey RS, Riser WH: Osteosarcomaof the canine skull. I Am Vet
Radiol Soc 8:5, 1967.
76. Myer W: Cranial vault and associatedstructures. In Thrall DE (ed): Textbook of
Veterinary Diagnostic Radiology, 3rd ed. philadelphia, WB Saunders, 1998, pp 45-59.
77. Lawson C, Burk RL, Prata RG: Cerebral meningioma in the cat: Diagnosis and
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.
Comp Contin Edu Pract Vet l3:41-48, 1991.
79. Sullivan M, Lee R, Jakovljevic S, et al: The radiological features of aspergillosis
ofthe nasal cavity and frontal sinusesin the dog. J Small Anim pract2T:167-1g0,19g6.
80. Haney CE, O'Brien lA, Felsburg PJ, et al: Nasal penicilliosis in six dogs. J An
Vet Med Assoc 178:1084-1087,1981.
81. Gibbs C, Lane JG, Denny HR: Radiological features of intra-nasal lesions in the
dog: A review of 100 cases.J Small Anim Pract 20;515-535,1979.
82. Mdik R, Martin P, Wigney DI, et al Nasopharyrgeal cr)?tococcosis. Aust Vet
75:483488, 1997.
83. Wilkinson GT: Feline cryptococcosis: A review and seven case reports. J Small
Anim Pract 20:749-768, 1979.
84. Hawkins EC: Chronic viral upper respiratory diseasein cats: Differential diagno-
sis and management.Comp Contin Edu Pract Vet 10:1003-1012,19gg.
85. Burgener DC, Slocombe RR Zerbe CA: Lymphoplasnaqtic rhinitis in five dogs.
J Am Anim Hosp Assoc23:565-568,1986.
86. Tasker S, Knottenbelt CM, Munro EAC, et al: Aetiology and diagnosis of persis
tent nasal disease in the dog: A retrospective study of 42 cases.J Small Anim pract
40:473478, 1999.
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.
88. Gibbs C: The head-Part III; Ear disease.I Small Anim pract 19:539-545,1978.
89. Hoskinson JJ: Imaging techniques in the diagnosis of middie ear disease.Semin
Vet Med Surg (Small Anim) 8:10-16, 1993.
90. Hofer P, Meisen N, Bartholdi S, et al: Radiology corner: A new radiographic
view of the feline tympanic bullae. Vet Radiol Ultrasound 36:14-15, 1995.
91. Remedios AM, Fowler lD, Pharr fW: A comparison of radiographic versus
surgical diagnosis of otitis media. J Am Anim Hosp Assoc 27:183, 1991.
92. Love NE, Kramer RW, Spodnick Gl, et al: Radiographic and computed tomo-
graphic evaluation of otitis media in the dog. Vet Radiol Ulirasowd36:375-379, 1995.
93. Barthez P! Koblik PD, HornofWJ, et al; Apparent wall thickening in fluid filled
versus air filled tympanic bulla in computed tomography. Vet Radiol Ultrasound
37:95-98, 1996.
94. Stanton MLE: Feline nasopharlngeal and middle ear pollps. In Bojrab MJ (ed):
Disease Mechanisms in Small Animal Surgery, 2nd ed. philadelphia, Lea & Febiger,
1993, pp 128-129.
95. Kapatkin AS, Matthiesen Dl Noone KE, et al: Results of surgery and long-
term follow-up in 31 cats with nasopharyngeal pollps. J Am Anim Hosp Assoc
26:387-392,1990.
96. Ticer JW, Spencer CP: Injury of the feline temporomandibular joint: Radio-
graphic signs. J Am Vet Radiol Soc 19:146-156, 1978.
97. Lane JG: Disorders of the canine temporomandibular ioint. Vet Annu 2l:175-
186, r 982.
98. Padgett GA, Mostosky IJV: The mode of inheritance of craniomandibular osteop-
athy in West Highland White terrier dogs. Am J Med Genet 25:9-13, 1986.
99. Riser WH, Parkes LJ, Shirer JF: Canine craniomandibular osteoDathv.T Am Vet
R adi olSoc 8:23 31, 1q67.
100. Grove TK: Periodontal disease.In Harvey CE (ed): Veterinary Dentistry. philadel
phia, WB Saunders, 1985, pp 59-77.
W Ouestions
l What are the radiographic signs associatedwith hydrocephalus,
and what breeds are most commonly affected?
86 AXIALSKELETON

Figure 7-27. cat with mandibularswelling'

Lateralradiographof a 12-year-old

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

2. What are the causes of hlperparathyroidism? What radio-
graphic changesare seen on skull radiographs?
3. What are the two most useful radiographic views for evaluating
nasaldisease?
4. What are two radiographic signs seenwith nasal cavity tumors?
5, Name three tumors affecting the mandible or maxilla.
6. You are presentedwith a l2-year-old domesticshorthairedcat
with a swelling of the Ieft mandible. The owner has brought in a
lateralradiographof the cat'sskull (Fig.7-27) from anotherveteri-
narian and would like a second opinion from you. What additional
radiographic view would be helpful? rrA/hatis a differential for this
radiographicappearance?
ffi CHAPTER
ffiB
ffi .EquineNasal Passagesand Sinuses
W Iimmv C. Lattimer
Radiographic examination is a useful technique for obtaining diag-
nostic or prognosticinformation regardingthe diagnosisof parana-
sal sinus and nasal cavity diseasein the horse.' Radiographic
examination of the ecuine head should be used in combination
l'ith clinical signs, endoscopy, physical examination, and clinical
pathologic tests to arrive at an accurate diagnosis. The decision
rvhetheror not to make radiographsshould be basedon the need
to answer specific questions indicated by the clinical signs and
physicalexamination.Clinical signs suggestingthe need for radio-
graphic examination include nasal discharge,nasal airway obstruc-
tion, facial swelling, epistaxis (particularly unilateral), dental de-
fects,draining tracts, epiphora, and facial deformity.'
The task of radiographingthe head of a conscioushorse may be
formidable. Many horses are frightened by the procedure, so seda-
tion is usuallydesirable.Most horses,while standing,are in motion
from respiration; this postural shifting is also reduced by sedation.
-\nesthesiahas been recommended for radiographic projections
other than the lateral projection.'zThe need to induce general
anesthesiato obtain satisfactory radiographs makes difficult the
decision whether or not to radiograph the skul1,especiallyin a
clinically ill animal. However, modern developmentsin radio-
eraphic equipment have made standing radiography of the equine
head technically feasible,if not easy.
One of the greatestdeterrentsto radiographyof the equinehead
is the complexityof the image.The 1arge,multiple, interconnecting
air passagesand turbinates, combined with the many sharp and
irregular external bony prominences,make skull radiographs a
challengeto interpret. When radiographic anatomy is so complex,
rt is easyto overlook even relativeiy major lesions. It is, therefore,
imperative that a systematicmethod of evaluating the radiograph
be used.It is alsonecessary that sometype of radiographicanatomy
referencebe consultedbecausecomparisonof the radiographwith
a known normal image usually resoives any questions regarding
rrhether or not a structure in cuestion is abnormal.
\lany radiographicprojectionsof the skull may be made, but it
is not necessaryto perform them a1l in any given instance.The
ratrent's clinical signs dictate the exact projections to be made.
This is especiallytrue when facial trauma or distortion is present.
Radiographs should be made in such a way that any visible alter-
E qui neN asalP assages
an d Sinuses a7
7. \A/hat is the most common cause of destructive rhinitis in
the dog?
8. You are presentedwith a l-year-old Golden retriever dog with
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
radiographic findings, and what is your assessment?
9. What are the clinical and radiographic signs of an abscessof
the fourth ma,xillary premolar tooth in a dog?
10. What breeds are typically affectedby craniomandibular osteop-
athy? What age group of dogs does it affect?
Answers begin on page 727.
ation in the shapeofthe face is projected tangentially. Occasionally,
especiallyin instancesof dental disease,the diseaseis best demon-
stratedwhen the central ray of the beam is positioned perpendicu-
lar to the area of the lesion, that is, "en face." However, as a ru1e,
the tangential projection is usually more rewarding. When no
externally visible effects are apparent, the standard lateral, ventro-
dorsal, and oblique views should be made initially. Once abnormal-
ities are detectedon theseviews, further projections may be tailored
to enablemore completeevaluationof the diseaseprocessif neces-
sary. When special nonstandard views of the skull are made, it is
advisable that either symmetrical views of the patient's other side
or the same view of a presumed normal subiect be made to
facilitate detection of minor anatomic abnormaliiies,
I Normal anatomy
The most obvious extranasallandmarks on the lateral view of the
nasal passageare the large molar and premolar teeth, although they
are partially surrounded by the sinuses.These teeth provide a con-
stant point of referencefor lesion localization. It is alwaysadvisable
to use a field-of-view of suffrcient size so that either the second
premolar or the third molar is identifiable. Another external struc-
ture that is usually evident over the caudal portion of the nasal
passageis the zygomatic arch, which is also superimposedover the
orbit. The zygomatic arch continues rostrally as a linear region of
bone opacity, which representsthe facial crest. Depending on the
exact cassetteorientation and exrosure factors used. the facial crest
may or may not be apparent. Identification of the facial crest and
first maxillary molar is important in that their rostral limits define
the rostral iimits of the caudal and rostral maxillary sinuses,respec-
tively (Fig. B-1). Becausethe two compartments of the maxillary
sinus do not usually communicate, except in mules and donkeys, it
is important to determine which of the cavitiesis affected.3'a
Internal nasal cavity landmarks include the rostral limits of the
dorsal and ventral conchal sinuses,the rostral limits of the maxil-
lary sinus, and the ethmoid turbinates (seeFig. 8-1). Theseland-
marks basically define the limits of the paranasal sinuses,making
it possible to determine if the diseaseprocess being observed
involves the sinuses,the nasal cavitx or both.
88 AXIALSKELETON

results in shortening of these roots. By the time the horse is 15 to

20 years old, the roots of the teeth do not obscure as much of the
nasal passageand sinuses.Thus, abnormalities of the nasal passage
may be more readily apparent in older than younger animals.
On the ventrodorsal projection, much of the nasal passageand
paranasal sinus area is obscured by the mandible and the teeth.
Therefore, the usefulnessof the ventrodorsal view is limited princi-
paliy to evaluation of midline structures. The nasal septum and
common meatus are well visualized on the ventrodorsal view.
Unlike in the dog,' the nasal septum in the horse, along with its
attached mucosa, contributes markedly to the midline opacity of
the nasal cavity.'gThe septal structures are representedby a linear
but slightly bulging radiopacity bordered on either side by the
radiolucent common nasal meatus (Fig. 8-3). Slight obliquity of
::::
the projection affects both the projected width of the septum and
i,::.:::.:
:li6lr'rl: the relative widths of the common nasal meati, making detection
a).).-,lL:..,.
ffiil and description of diseasedifEcuit. Therefore, good positioning on
Figure 8-1. Lateral viewof the nasalpassage of a younghorse.A, Rostral the ventrodorsal view is mandatory.
marginof the dorsalconchal margin
sinus;B, Rostral of the ventral
conchal The paranasalsinusesof the horse are large and complex. To-
sinus;C, Rostral
margin sinus;D, Firstmaxillary
of the maxillary cheektooth; gether with the nasal cavity, they account for most of the volume
E,Intermaxillarv
septum; canal;
t lnfraorbital G,Ethmoid 4 Rostral
turbinates; of the skull. There are six pairs of sinusesin the horse. The dorsal,
marginof thefrontal
sinus.
middle, and ventral conchal sinuses are within the turbinates of
the same name. Lateral to the nasal cavity is the maxillary sinus,
which is dividedinto rostraland caudalcomDartments. Dorsaland
The ethmoid turbinates are the most consistently placed of the caudal to the nasal cavity is the frontal sinus. Ventral and caudal
internal landmarks. They mark the caudal limit of the nasal cavity to the nasal cavity and the ethmoid turbinates is the sphenopalatine
and are, for radiographic purposes, interposed between the maxil- sinus. All of the sinus cavitieson one side of the skull communicate
Iary and frontal sinuseson the lateral projection. The finely scrolled freely, with one exception. The rostral maxillary sinus generally
bones of the ethmoid turbinates are readily visible as numerous does not communicate with the remaining paranasalsinuses,except
fine, linear opacities that rise from the cribriform plate (Fig. 8-2). in some mules or donkeys.anThe frontal sinus communicates with
The rostral limit of the maxillary sinus is immediately dorsal to the dorsal conchal and caudal maxillarv sinuses:the caudal maxil-
the root of the fourth maxillary premolar and may vary somewhat Iary sinus communicates with the frontal, middle conchal, spheno-
in position from horse to horse and with age; it may be completely palatine, and ventral conchal sinuses.
obscured in young horses owing to tooth overiap. The dorsal and The maxillary sinusesare relatively larger in the mule and the
ventral conchal sinusesdo not extend as far rostrally as the maxil- donkey than in the horse.aThe septum between the two compart-
lary sinuses. The thin plates of bone that define their rostral ments of the maxillary sinus is usually visible as a thin, angled
margins are usually seen dorsal to the first maxillary molar. The (vertically to slightly caudally) bone plate dorsal to the first molar
dorsal sinus is located just below the nasal bone; the ventral sinus (seeFig. 8-l).5 In mules and donkeys,the septum is more irregular
is iust beneath the dorsal sinus and extends slightly more ros- and less laminar in appearancethan in horses. This septum may
trally.s-7 The middle conchal sinus in the horse is small, and not be seenif there is obliquity to the radiograph becausethe thin
landmarks attributable to it are not usuaily observed. The nasal plate is easily overpenetrated unless it is oriented parallel to the
turbinates are not recognized as well-defined structures and are x-ray beam. The septum is also visible on oblique projections
representedonly as multiple scallopedopacities in the dorsal caudal of the maxillary sinus, for example, a ventral 15-degree lateral
portion of the nasalpassage. dorsomedial view. This view allows most of the lateral oortion of
In young horses, the long roots of premolars two through four the maxillary sinus to be seen in profile without the interference
and the molars overlap and, when seen on the lateral view (see of the overlying teeth. Both sides of the skull must be examined
Fig. 8-1), obscuremuch of the ventral portion of the nasalpassage radiographically, which serves as an internal control. It is easy to
and paranasal sinuses.Continuous tooth wear as the animal ages incorrectly interpret the opacify of the overlying massetermuscle

Figure 8-2. Slightlyoblique,lateralview of the caudalnasal

passagein a 12-year-oldhorse. A, Rostral margin of dorsal
conchalsi nus;8, R ostralmargi nof ventralconc hals i nus ; C ,
R ostralmargi nof maxi l l arysi nus;E Intermaxi l l ary
s eptum;E
Infraorbitalcanal; G, Ethmoidturbinates;H, Rostralmargin of
the frontalsi nus.

view of the nasaipassage.
Figure 83. Ventrodorsal C, Commonnasal
nneatus;
M, medial
border
of mandible;O,medial
wallof orbit;S,nasal
septum.
as fluid in the sinus if the angle of the projection is not optimal.
The l5-degreeoblique projection usually enablesbetter evaluation
of the maxillary sinus than does the lateral view or the more
conventional 30- to 4O-degreeoblique view, which is designed
to project the roots of the molars and premolars rather than
the sinuses.
Identification of the septum between the compartments of the
maxillary sinus allows the determination of which of the two
compartments is affectedby disease.Fluid is more readily retained
l'ithin the rostral compartment becausethe nasomaxillary opening
of the sinus is located at the highest point in the sinus.3The
nasomaxillary opening of the sinus is common to both the rostral
and caudal maxiilary sinuses,but it is divided by the septum. This
aperture, which empties into the middle nasal meatus, is usually
the sole site of drainage of the paranasalsinus system into the
nasal cavity; it is not visible radiographically.
The infraorbital canal passeslongitudinally through the maxil-
lary sinus, dividing it into lateral and medial portions. The caudal
medial compartment communicates with the sphenopalatine and
middle conchal sinuses.The infraorbital canal is located immedi-
ately dorsal to the roots of the teeth; in the young animal, it is
r irtually in contact with them as they project into the ma-xillary
sinus.The canal is usually seenas a band of increasedopacity that
runs longitudinally just above the teeth on the lateral view (see
Fig. 8-2) but is not readily seenon oblique or ventrodorsalprojec-
iions.r'5'eThe normal root shorteningthat occurswith aging results
;n better visibility of the maxillary sinus and leavesthe infraorbital
canal more obviously in the middle of the sinus on the lateral view.
The caudal limits of the maxillary sinus are difficult to recognize
:adiographically. Its communication with the sphenopalatinesinus,
ihe overlying teeth and ethmoid turbinates, and the vertical man-
dibular ramus make the caudal iimits indistinct. Fortunately, identi-
ication of the caudal limit is not usually necessary.For the pur-
:oses of radiographic interpretation, the maxillary sinus ends at
:he level of the ethmoid turbinates caudally and at the level of the
E qui neN asalP assages
and Sinuses 89
frontal sinus caudodorsally.It should be recognized that the third
molar projects into the caudal part of the caudal maxillary sinus.
The frontal sinus is dorsocaudal to the nasal cavity; its radio-
graphic limits are not as extensiveas its anatomic limits becauseof
the presenceof overlying bone. It is relatively larger in the donkey
than in the horse and mule.' Radiographically, the frontal sinus
comprises two parts: the roughly triangular dorsocaudal portion
and the portion rostral to the orbit (see Fig. B-2). The triangular
part is dorsal and caudal to the ethmoid turbinates on the lateral
view and tends to be radiolucent in the normal horse. The marked
radiolucency is due to the relatively great width of the sinus at this
point. This part of the frontal sinus communicates with the maxil-
Iary sinus through the frontomaxillary opening.3 The rostral por-
tion of the sinus is rostrodorsal to the ethmoid turbinates and has
a scalloped cranial margin that is dorsal to the second molar; this
margin is readily seen on many radiographs.3The rostral portion
of the frontal sinus communicates openlv with and is continued
forward by the dorsal conchal sinui. TLe dorsal conchal sinus
usually terminates at the rostral margin of the first molar; it is
superimposedover the dorsal half of the nasal passageand is
somewhat tubular. Other than the most caudal oortion of the
frontal sinus, the dorsal conchal sinus is the mosi medial of the
paranasal sinuses. It virtually touches the midline owing to the
small size of the dorsal nasal meatus. Becauseit is located so close
to the midline, it is superimposedover the nasal passageon the
ventrodorsal projection. Filling of the dorsal conchal and frontal
sinuseswith fluid or tissue causesincreasedopacity in these areas;
incomplete filling may lead to the development of a fluid level in
standinglateral radiographs.
The sphenopalatinesinusesare relatively small in the horse and
usually are not recognized as separateentities. This fact is due to
their size and also to the marked opacitv of the vertical rami of
the mandibles. If they can be recognized, these appear as small
radiolucent areasjust ventral to the cranial vault and caudal to the
ethmoid turbinates. Their caudal termination usually occurs at
about the 1eve1 of the temporomandibularjoint.?
I Radiographic abnormalities
Disorders of the nasal passage
Clinical signs of nasal diseasemay consist of nasal discharge,
noisy or restricted respiration, facial distortion, dental defects,sinus
tracts, epiphora, and epistaxis,in any combination.t,, The list of
possible differential diagnosesindicated by this list of clinical signs
is long and includes both local and systemic diseases.Diseases
such as infectiousrhinitis, purpura hemorrhagica,congestiveheart
failure, emphysema,and pneumonia may causenasal dischargeor
epistaxis, but these conditions are unlikely to result in significant
radiographic abnormalities in the nasal passagesunless there is
fluid collection in the sinusestcD(Fig. B-4).
Fractures of the nasal bones are common. Any visible facial
deformity is frequently less pronounced than the underlying bony
injury. Profuse epistaxisis usually associatedwith the acute injury.13
A chronic mucopurulent discharge may develop if the fracture is
untreated and a piece of depressedbone triggers an infectious or
foreign body reaction.
Radiographically and clinically, a fracture of the nasal region is
usually recognizedas a depressedarea in the bone (Fig. B-5).
Occasionally,a large piece of bone is depressedinto the nasal
passagesor into a sinus (Figs. 8-6 and B-7).8 The true extent
and severity of the fracture are usually difficult to delineate on
radiographs, and the fracture is almost invariably found to be more
extensive at surgery. It is a good idea to obtain at least one
projection tangentto the suspectedfracture.The bones of the nose
are quite thin, and if a fracture fragment is not struck end on by
the x-ray beam, it may not be recognized.Tangentialprojections
have the best chance of revealing displaced fragments. It may be
90 AXIALSKELETON

Figure 84. Horse with small amounts of fluid in multiplesinuses (arrows).Small

amountsof fl ui d such as thi s are often seen i n casesof si nusi ti sthat are as s oc i ated
wlth other upperairwayinflammatorydiseases.

Figure 8-5. Depressedfracture of the maxillarybone There are

severalsmall fragmentsdisplacedinto the dorsalportionof the nasal
passages(arrows).From the positionof these fragments,it is likely
l n ch asin
t hatt he r e h a sa l s ob e e n i nju r yto th e d o r sa co l us
 E qui neN asalP assages
and Sinuses 9l

lesions(adamantinomas)or as well-defined,bony, expansilelesions

(osteomasor odontomas,Fig. 8-9). Benign tumors such as these
lay be relatively silent clinically, and thus may become quite large
before a diagnosis is made.
Malignant lesions, usually adenocarcinomas,occur in older ani-
mals and are invasive, grow rapidly, and are ill defined.11'16The
clinical signs usually include unilateral mucopurulent nasal dis-
charge, epistaxis, facial deformities. and upper airway obstruction.
The severity and type of clinical signs are dependent on the stage
and location of the diseasewhen it is first evaluated.Radiographi-
cally, malignancies are of soft-tissue opacity and are ill defined
(Fig. 8-10). There may be lysis of tu;binare and facial bones.
Rarely, invasion of the cranial vault through the cribriform plate
may occur.rTDistortion or destruction of the nasal septum mav
be obvious on the ventrodorsal view, and advanced tumors may
demonstrate bilateral involvement or may project caudally into the
nasopharynx.
Intranasal cysts usually occur in young animals and may be
congenital.l8These lesions are large, fluid-filled structureswithin
the nasal passageor sinuses.They may causefacial deformity and
nasal discharge,but becauseof their benign nature, intranasal cysts
,,:lll9:::rll, are usually quite large when they are recognized.Radiographically,
l,.,tt9l::.ltI"'
these cysts appear as large, well-defined areasof increaied opacity
:iiilcllt,iiell,, within the nasal passage;they may be single or multiple, unilateral
!llll:illil!lll,,.:l
llg,,illlr: or bilateral (Fig. 8-11). As they grow, theselesions displacebone
llglll-l9rlr,,
ut;il@u,.ittl
structures, especially the turbinates. The nasal septum is often
displaced.There is usually nothing visible radiogiaphicallythat
distinguishes a cyst from a large, weil-defined soft-tissue tumor or
ethmoid hematoma,other than possiblythe location of the lesion.
However, a well-defined dental structure or aberration in dentition
may be evident in horses with an intranasal dentigerous cyst (Fig.
Figure 8-6. Largedepressed maxilaryfracture.A largepece of cortical
conehasbeendisplacedintothemaxiliary
sinusiwhiteaffowsl.Othersmaller
-iagmentsarealsoseen(black
anows).

diffrcult on one view to recognize a fracture that is quite obvious

on another. Therefore, standard lateral and ventrodorsal projec-
tions should also be obtained (seeFig. 8-7).
Foreignbodies are an uncommon sourceof trauma to the nasal
passages. Small foreign bodies are often not problematic,but large
objects, such as sticks, wire, and bullets, may lodge within the nasal ::4....
passageand cause a foreign body reaction (Fig. 8-8). Foreign ll..rll:
llil:::,
',iutl
bodies in the ventral or common meatus may be detected and
removed by endoscopicprocedures.In other instances,however, $l,,lllll
r,.il@ll
radiography may be needed to localize the problem, especiallyif i1$ltr..
rhe foreign body is in the dorsal or lateral portion of the nasal
;aviry. A foreign body reaction within the nasal passageusually
.ippears as a poorly defined area of increased radiopacity. If the
ioreign body is radiopaque,it is generallyvisible in the middle of
ihe area of increased opacity. Organic objects such as sticks are
-.Iten not recognizableradiographically. Becauseforeign bodies are
their location may be detectedon the ventrodor-
.j,"i1y*:"tt"ral,
Uncomplicated rhinitis is unlikely to result in radiographic
:hange. Only if rhinitis is associatedwith sinusitis or some other
:rnormality, such as a foreign body or a nasal deformity, is it likely
:erbe radiographicallyobvious. The most one may expectto per-
:eive is a slight increasein the opacity of the nasal passageand
:erhaps a slight narrowing ofthe airwayson the ventrodorsalview.
Trese subtlefindings,which are highly susceptibleto aberrationsin
-:chniqueand positioning,shouldbe supportedby other diagnostic
:roceduresbefore a diagnosisof rhinitis is made.
\asa1 tumors are uncommon in the horsebut occasionallyoccur.
,:e nasalpassagemay be the primary location of the tumor, or it Figure 8-7. Ventra dorsalobliqueview of the maxiila(samecaseas that in
:l;r- fs secondarilyinvaded from one of the sinuses.The benign Fi gure8-3). There i s a very thi n pi ece of corti calbone d i s pl ac edrnto the
maxil arysi nusbel owthe l evelof the otherl argerpi eces.S u c hs mal lpi ec esof
-:,;ons are usuallyosteomasor adamantinomasand occur in young bone coul deasi l ybe m ssed on othervi ew s or at surgery.Chroni crhi ni trsor
.:ima1s.]a'15These lesions may present as expansileradiolucent si nusi ti sare i kel ysequeae i f thesesmal lfragmentsare not remov ed.
92 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.

Figure 8-9. Tumor of dental germinaltissue origin in the

inc is i v eb o n e . T h i s i s a be n ig ntu m o r th a t is e xp a n silea n d
causes destructionof the tooth roots and distortionof the
surroundingbony structuresby pressureexpansionratherthan
inv as i o nR. e m o v aol f s u c ha le sio nis cu r a tiveif co m p le te .
 E qui neN asalP assages
an d Sinuses 93

,-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
may result from occlusion of the drainage pathway by large cysts.
Non-neoplastic polyps are often seen in the nasal passagesof
young horses. These lesions are usually composed of granulation
tissue and are probably associatedwith chronic inflammation.tl'18
Polyps may be recognizedradiographically as relatively well-defined
areas of increased opacity within the nasal passage;they vary in
size and number. Clinical signs may be delayed until the polyps
are of sufficient size or number to interfere with respiration.
Deviation of the nasal septum is easily detected on the ventro-
dorsal projection. This deviation may result from an intrinsic
disease,such as cyst formation, or from Pressure from a mass
within the nasal passage.It may be a benign anatomic variation
with no clinical significance(Fig.8-13). The degreeand site ofthe
deviation are usuaily obvious, but the underlying cause may be
difficuit to determine.
A special form of cystic disease occurs in the nasal septum.
Varying amounts of the nasal septum in young horsesmay undergo
cystic degeneration as the result of trauma or infectionte (see Fig.
8-13). The nasal septum widens substantially,which interferes with
respiration. Both radiographic and endoscopic examinations of the
nasal passagesare needed to adequately evaluate the extent and
severity of the probiem. Cystic diseaseof the sePtum is one condi-
tion for which the ventrodorsal projection is mandatory. The lateral
view is of minimal help for determining the severity of the thick-
ening of the septum, although it may aid in establishingthe caudal
limit of the problem. Accurate evaluation of the extent of the
lesion is imperative becausesurgical resection of the affected septal
portion is usually the only effectivetreatment. Postoperativeradio-
graphic evaluation must wait until after the removal of the packing
used to control the profuse hemorrhage induced by surgery.When
the postoperative radiograph is evaluated, consideration must be
given to the fact that, although the nasal septum is a major
contributor to the midline opacity of the nasal passages'it is not
the only midline opacity.e Persistenceof some midline opacity'
therefore, does not indicate inadequate resection'
Progressiveethmoid hematoma is a slowly enlarging hematoma
that contains granulomatous reactions; it originates from the sub-
15
mucosa of an ethmoid endoturbinate.l2'ta' It is not known why
the mass continues to enlarge, as it is not neoplastic. Extension
into the maxillary, frontal, and sphenopalatine sinuses' as well as
into the nasal cavity, is common. Distortion and destruction of the
ethmoid and nasal turbinates and nasal septum are frequent. The
clinical signs of inspiratory stridor, coughing, choking' excessive
salivation, purulent nasal discharge,haiitosis, and head-shaking are
characteristicfindings. Facial deformity may or may not be present.
There is often a history of chronic epistaxis.Endoscopy may reveal
a large, smooth-walled, greenish mass in the caudal part of the
nasalpassages.ls'20 A hematomain the dorsal caudalportion of the
Figure 8-12- Dentigerouscyst: The arows outline the well-
circumscribed,highly dense tooth structure at the center of a
dentigerouscyst. Such cysts may be present for several years
before becomi ngcl i ni cal l yevi dentow i ng to sl ow ex pans i onof
the cvst.
nasal passage may not be visible endoscopically. Although the
differential diagnosisfor these clinical signs is extensive,a thorough
physical examination combined with the results of endoscopic
and radiographic examinations should make the diagnosis easy to
establish.'?l
The radiographic examination of progressiveethmoid hematoma
should consist of lateral, ventrodorsal, and oblique maxillary sinus
projections. Single lesions are usually confined to one side of the
nasal passage,but these lesions may deform the septum and the
ethmoid turbinates. Multiple lesions are occasionallyseen and may
appear on both sides of the septum. Ethmoid hematomas are
usually seen as round, smooth-walled, soft-tissue masses arising
from the region of the ethmoid turbinates (Fig. 8-14).'&'zo' 'z'Calci-
fication and air trapping within the lesion have not been described.
Overt destruction of dense cortical bone is not a feature of this
disorder, which may help one to distinguish it from malignancies,
which also occur in the same areas.Becauserecurrenceis common,
re-examination is advised at 6-month intervals for at least 2 years
after the lesion is removed.tt
Disorders of the paranasal sinuses
Lesions in the paranasal sinusestend to parallel those seen in the
nasal cavity-traumatic fractures, cysts, tumors, and empyema.
Ethmoid hematomas also invade the sinuses.ls'20
Fractures of the sinusesare similar to nasal bone fractures. Once
again, the physical appearance of the face may not indicate the
true extent of the lesion. When fracture fragments are depressed
into a sinus, there is an even greater likelihood that infection
wili develop because of reduced drainage and air exchange.The
radiographic approach to the diagnosis of paranasalsinus fractures
is the same as that for fractures of the nasal passage.Whenever a
fracture line enters a sinus, special attention should be given to
any increasedopacity within the sinuses.Infection or injury to one
sinus may affect all of the sinuseson that side, and fluid lines and
increased opacity within the sinuses may be seen quite removed
from the actual site of injury.
As is seen in the nasal cavity, benign sinus tumors are usually
osteomas or adamantinomas that arise from or around the roots
of the teeth within the maxillary sinus." Malignant neoplasms (see
Fig. 8-10) are either primary (adenocarcinomaand fibrosarcoma)
or secondary (extension of a squamous cell carcinoma from the
orbit).13,", " Malignant tumors are ill-defined, lobulated-to-diffuse
soft-tissue lesions. Lysis of cortical bone and deformity of facial
bones are common, as is periosteal new bone growth. Focal calcifi-
cations, radiolucencies, or both may be seen within the tumor
mass.16With primary tumors, much of the opacity within the
sinuses may be the result of trapped secretions because the neo-
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
opacity may therefore be substantially larger than the true area of
neoplastic involvement. The trapped secretionsmay also silhouette
with the tumor, resulting in fluid lines on standing lateral projec-
tions and mimicking the radiographic appearanceof sinusitis.
Secondary invasion of the frontal sinus by a squamous cell
carcinoma of the orbit is an unusual, but serious, finding. There is
usually obvious bony destruction of the orbit. Because of the
possibility of orbital tumors extending through the bone into the
frontal or maxiilary sinus, it is advisablethat radiographic projec-
tions be made that are designedto project the orbital margins and
maxillary sinus. Most orbital neoplasmsdo not invade the sinuses,

Figure 8-15. Distinctfluid level in the caudalmaxillarysinus.Suchfluid levels

mav be presentwith severaldiseaseorocesses.However.sinusitisis the most
w i th
commoncauseand si nusi ti si n ol derhorsesi s most frequentl yas s oc i ated
di s eas eproc es s es
dentaldi sease.Fl ui di n the si nusesmay obscureunderl yi ng
suchas dentaldi sease,tumors,and ethmoi dhematomas.
 E qui neN asalP assages
an d Sinuses 97

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
sinus regions ofthe horse. II. Radiological findings. Equine yetl 19i474' 1987.
24. Schumacher J, Honnas C, Smith B: Paranasalsinusitis complicated by inspissated
exudate in the ventral conchal sinus. Vet Surg 5:373, 1987.
25. Beard WL, Robertson JT, Leeth B: Bilateral congenital cysts in the frontal sinuses
of a horse. I Am Vet Med Assoc 196:435, 1990'
26. McClure SR, Schumacher J, Morris EL: Dentigerous cyst in the ventral conchal
sinus of a horse. Vet Radiol Ultrasound 34:334, 1993-
27. Lane tG, Longstaffe lA, Gibbs C: Equine paranasal sinus cysts: A report of 15
cases.Equine Yet J 19:537, 1987-
ffi Ouestions
views) in horses suspectedof having experiencedtrauma to the
nasal passages?
4. In Figure 8-17, what are the two major radiographic lesions
evident on this lateral radiograph of the nasal passagesin a
horse that was presentedwith a nasal discharge?
5. What radiographic proiection of the nasal cavities would best
enable visualization of lesions of the nasal septum?
6. What structure overlies the maxiliary sinus on the straight
ventrodorsal view of the nasal passagesand can give the false
impression of sinusitis?

7. \{hen a large soft-tissue lesion in the nasal passagesor sinuses

1. At what level is the septum separating the rostral and caudal is evaluated,what radiographic finding would be virtually con-
compartments of the maxillary sinus? firmatory of a neoplastic process?

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

I Anatomic principles 4. On a lateral view the cervical articular processesare posi-

The following are important basic anatomic principles regarding
the canine or feline spine:
1. There arc 7 ceryical, 13 thoracic, 7 lumbar, 3 sacral, and
betrveen6 and 23 caudal vertebrae.l
2. Most of the vertebral ossification centers that are present at
birth close between 7 and 14 months of age; those in Cl and C2
close between 3 and 9 months of age. Cl has 3 centers of ossifica-
tion, C2 has as many as 10, and the remaining vertebrae have
5 each.'?
3. The spinous processof C2 should be adjacent to or overiap
the arch of Cl.
tioned obliquely across and superimposed on the intervertebral
foramina and vertebral canal.
5. C6 has a large ventral lamina that is an important distin-
guishing radiographic landmark.
6. Rib heads are cranial to their corresponding vertebrae.
7. T11 is the anticlinal vertebra.
8. The T10-T11 intervertebral disc space is normally more
narrow than other disc spaces.
9. Adjacent intervertebral disc spaces should be of approxi-
mately equal width.
10. Adjacent vertebrae should be approximately equal in size,
shape,and radiopacity.
 The Vertebrae-Canineand Feline 99

Figure 9-3. Lateralview of the lumbosacral spineof a dog with cauda

equina syndrome.
Thefirstsacralsegment is incompletely
fusedto theremain-
derof thesacrum,
suggestiveof a parta transitional
vertebra.

processedradiograph of the spine is often nondiagnostic and

should be repeated(Fig. 9-1).

f Anomalies of the vertebrae

Figure 9-1. A, Malpositioned spineillustrating Spinal anomalies occur fairly commonly; most are clinically incon-
lateralview of the cervrcal
the difficulty
of accurateinterpretation
introduced by poorpositioning.
B, Cor- sequential.The most common anomalies of the spine include
rectlypositioned lateralview of samecervical spine.The vertebrae,their variations in the number of vertebrae (excessiveor fewer than
articularprocesses,andthe intervertebraldiscspacesarec earlyseen.
normal numbers of vertebrae, block vertebrae, and transitional
vertebrae) and incompletely formed vertebrae (hemivertebrae,
spina bifida, and agenesisor incomplete development of the dens
11. The intervertebralforamina serve as radiographicwindows of C2) (Figs.9-2,9-3,9-4,9-5, and 9-6). Number abnormalities
to the vertebral canal. imply an excessor deficiency of parts. In many instances,number
12. The ventral cortex of the L3 and L4 vertebral bodies may changesare clinically insignificant. In one study of I45 dogs, To/o
appear poorly defined owing to origins of the diaphragmatic crura. had variations from the normal number of vertebrae.aApparent
This is particularly true in large dogs. variations in the number of vertebrae may result from an animal
13. The three sacral vertebrae fuse by 1 year of age. having ribs associated with the seventh cervical vertebra, from
14. The lumbosacral angle is variable among individuals and missing l3th ribs resultingin iumbarization of T13, from sacraliza-
also varies with flexion or extension of the lumbosacral joint. tion of L7, from lumbarization of S1, from fusion of 53 with CYl,
15. The vertebral canal should be smoothly aligned. or from the presenceof other block vertebrae.
16. Bony hemal archesmay be present as separatebones ventral Excessivevertebrae usually manifest as an extra lumbar vertebra.
to caudal vertebrae 4 through 6. Small hemal processesmay be A false impression of eight lumbar vertebrae may occur if there is
present ventral to the next few caudal vertebrae.l-3 a transitional yertebra present (see Fig. 9-3). Examples include
agenesisor incomplete formation of the 13th ribs and lack of
Proper radiographicpositioning may require the use of sedation
or general anesthesia.In instances of suspected spinal fracture,
however,loss of the patient's pain perception may allow for hazard-
ous manipulation of the unstable spine. Good judgment is neces-
sary in every instance. An improperly positioned, exposed, or

Figure 9-4- Hemivertebrain the midthoracicspine (arrow)resultingin mal-

Figure 9-2, Blockvertebrae(arrow)fromtwo f usedlumbarvertebralbodies al rgnment.
IOO AXIALSKELETON
Figure 9-5. Ventrodorsal spinein whichspina
view of the cervicothoracic
of the T1 andT2 spinousprocesses
bifidawith duplication can be seen
(arrows).
fusion of the first sacral vertebra with the sacrum. Lack of fusion
of the first sacral vertebra with the remainder of the sacrum is
referred Io as lumbarization of the sacrum. Lumbarization may be
asymmetrical, meaning unilateral in formation, or complete, mean-
ing that the transitional vertebra is bilaterally uniform in shape
and in associationwith the pelvis and sacrum. With lumbarization,
a concurrent anomaiy may occur in which the first caudal vertebra
becomessacralized,so that the number of sacraivertebrai segments
remains at a normal number of three.t'6
Occasionally,there is a iower than normal number of vertebrae
in either the thoracic or the lumbar spine. It is helpful to count
the ribs and to determine the location of the anticiinal vertebra
when deciding which part of the spine is anatomically deficient;
however, anomalous lack of the 13th pair of ribs and change in
location of the anticlinal vertebra may occur. L7 may be a transi-
tional vertebra, being partially or completely fused with the first
Figure 9-6. Atlantoaxial subluxation.Note increasedspacebetween lamina
of C1 and C2 hrrow). The dens is hvpoplastic.
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
Other examplesof improperly formed vertebrae include hemiver-
tebrae and spina bifida (see Fig. 9-4). A wedge-shapedhemiverte-
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
ventral portion of the vertebral body-hence, lhe term dorsal
or ventral hemivertebra. Hemimetameric disolacement results in
unilateral, left, and right hemivertebrae. The persistenceof sagittal
cleavageof the embryonic notochord results in the vertebral end
plates having a funnel shape and in failure of the central portion
of the vertebral body to form, producing a butterfly appearance
radiographically in the ventrodorsal view. The affected vertebrae
are called butterfly yertebraerather than hemivertebrae.e't0Either
adjacent vertebral bodies will compensate for the shapes of the
bodies of the hemivertebrae and butterfly vertebrae, or spinal
malalignment will result. Hemivertebrae and butterfly vertebrae
occur most often in the screw-tailed breeds of dogs such as bull-
dogs, French bulldogs, Pugs, and Boston terriers. Often, the kinked
tail in thesebreedsis due to caudal hemivertebrae.ll'1'
Spina bifida occurs mostly in brachycephalic dogs and Manx
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
br eeds.Chondrodystrophic dwarf sm manifests as disproportionate
body form, with short, thick limbs, short cranial base, and short

vertebrae that appear to have accordion-like bony protrusions from
the ventral surface of their vertebral bodies.
Lastly, in anomalous vertebral formations, one may seeunilateral
or bilateral lack of formation of the 13th ribs, causingT13 to seem
to be a transitional Ll vertebra, resulting in eight lumbar vertebrae.
Somewhat similarly, anomalous development of a transversepro-
cess of a lumbar vertebra may occur such that the transverse
process is abnormally elongated, mimicking a short rib. Either of
these anomalies could be significant when an attempt is made to
surgically iocalize a lesion in the thoracolumbar region.
I Alignment problems of the
I vertebrae
Although the vertebrae do not lie in one single dorsai plane, the
vertebral canal should alwaysbe smoothly aligned from one verte-
bra to the next. Abnormal curvatures of the spine include scoliosis,
a lateral bowing; lqphosis, a dorsal arching; and.lordosis,a ventral
deviation. Such abnormal contour of the spine may be congenital,
idiopathic, or related to another spinal abnormality. Congenital
alterations in spinal contour may result from hemivertebrae, in-
cluding unilateral hemivertebrae,causing scoliosis;ventral hemiver-
tebrae, causing lordosis; and dorsal hemivertebrae, causing kypho-
sis. Abnormal spinal contour may also be postural as a pain
response, or it may be from other deforming spinai abnormali-
ti e s.e '1 0
As described in the previous section, caudodorsal sublu-ration of
C2 may occur as a result of agenesis,fracture, or fusion failure of
the dens, or from rupture of the stabilizing ligaments between Cl
and C2. A lateral radiograph made during cervical flexion can be
used to visualize the sublu-ration, but care must be taken not to
overflex the neck and possibly compress the spinal cord by the
dens. Breeds affected most often include Yorkshire terrier, small-
breed Poodle, Pekingese,Pomeranian, Shih tzu, Dachshund, Chi-
huahua, and Maltese. Most affected dogs are younger than 1 year
ofage; however,trauma-induced atlantoaxial subluxation can occur
in any breed of dog at any age.1a'ls
Cervical yertebral malformation-malarticulation, also called "ca-
nine wobbler syndrome" and "caudal cervical spondylopathy," oc-
curs most often in young Great Danes and adult Doberman pinsch-
ers. C4-5, C5-6, and C6-7 are the most frequently involved sites,
and multiple lesions may be present. The abnormalities result in
static or dynamic compression of the spinal cord. A narrowing or
coning of the cranial aspect of the vertebral canal of the cervical
vertebrae may occur during the growth period of the dog; this
form of the condition is sometimes seen in Great Danes. The
Figure 9-7. Myelogramof the caudalcervicaispine. Note the
ankylosisor block vertebraof C6-7, with dorsal subluxationof
:h e s p i n ea t C 5 - 6 . T h e r eis m ild co m p r e ssio o
n f th e sp in a lcord
o y t h e s u b l u x aot n a nd b y a p r o tr u d in d
g isc.
The V ertebrae-C ani ne
an d Feline lO l
articular processesmay be malformed, possibly as a manifestation
of osteochondrosis; an abnormally large, flat articular processcan
be present and encroach upon the vertebral canal. Abnormal forces
on the caudal cervical vertebrae may be responsiblefor the malfor-
mation of a flattened or rounded cranioventral aspect of a caudal
cervicalvertebralbody (Fig. 9-7). Dorsal subluxationofthe cranial
end of C6 and C7 may occur and be d1'namic or static. D1'namic
changesare related to cervical flexion/extension. Adynamic changes
occur becauseof spinal stabilization by secondary changes.nch as
spondylosisdeformans.Myelographically,there may be iyperplasia
of the ligamentum flavum and secondaryinterverte6ral disc hernia-
tiOn. t6-1e
Degenerativeabnormalities of
I
I the vertebrae
Degenerativecanine lumbosacral stenosishas been defined as an
acquired radiculopathy resulting from any of severalpossible
causes.In the dog, degenerativelumbosacral stenosisand its associ-
ated cauda equina s1'ndrome may result from (1) an abnormally
narrowed or stenotic lumbar or sacral vertebral canal; (2) what
may be an osteochondrosis-likes;mdrome involving the craniodor-
sal aspect of the first sacral vertebral body; (3) lumbosacral mal-
alignment; (4) lumbosacral instability; (5) herniated discs and the
presence of fibrous connective tissue in the ventral aspect of the
vertebral canal at the lumbosacraljunction; and (O) ipondylosis
with or without vertebral diarthrodial joint osteophyteslmpinging
on the nerve roots at the interuertebral foramina of the lum6osJcral
junction (Fig. 9-B). A stenotic or abnormally narrowed vertebral
canal may occur at the last lumbar or at the first sacrai vertebral
segment. A small bone fragment from the craniodorsal aspect of
the first sacral segmentmay be a form of osteochondrosis.D1'namic
or static lumbosacral malalignment may occur.
Lateral radiographs may be made in neutral, hyperextension,
and hyperflexion positions of the lumbosacral ioint to help differ-
entiatethe dynamic versusthe static forms of the condition.Dy-
namic malalignment, or lumbosacral instability, is often seen best
on flexed views in which the sacrum subluxates ventral to L7.
Static maialignment may be evident on survey as well as on flexed
or extended lateral views. Affected dogs may exhibit decreased
extension, increased flexion, and reduced ranse of motion in the
lumbosacral joint. The lumbosacral interverte-braldisc soace mav
be narrowed, and there may be protrusion of the annulus fibrosui,
or herniation of the intervertebral disc. A hieher incidence of
transitional vertebrae has been reported in dogs-with degenerative
lumbosacralstenosisthan in normal does and has been considered
T
I AXIALSKELETON
IO2

Figure 9-8. Epidurogramof the lumbosacraljunction.There is

of the sacrum,and a protrudl n gdi s c i s c om-
ventralsubl uxati on
pressi ngthe nerveroots.S pondyl osiof
s L7-S 1 i s pre s entand the
disc spaceis narrowed.

a causativefactor for degenerativelumbosacral stenosis'Lumbosa-
cral spondylosis has been associatedwith dynamic malalignment'
but neither spondylosis nor lumbosacral instability is necessarily
indicative of cauda equina slmdrome or degenerativelumbosacral
stenosis. Both spondylosis and lumbosacral instability may occur
in older, large-breed dogs without clinical signs of cauda equina
syndrome. However, spondylosis can result in a narrowing of the
vertebral canal or of the neural foramina, and it may causeclinical
signs.s'6''c25Opinion varies as to the optimum imaging method
for assessmentof the lumbosacral space; in addition to routine
radiography, current methods include an objective measurementof
the lumbosacral vertebral canal obtained by measuring flexion and
extension angles,as well as the use of epidurography, discography,
computed tomography (CT), and magnetic resonanceimaging
(Figs.9-9 and 9-10).'?6-30
Spondylosis, or spondylosisdeformans, has been defined as "a
peridiscal collar of new bone beginning at the attachment of the
outermost annular fibers (Sharpey's fibers), where the bony end
plate meets the ventral and lateral cortex of the vertebral body''
(Fig. 9-11). The bony lesions are noninflammatory, and the verte-
bral body remodeling may vary in extent from small vertebral
epiphysealspurs to complete bridging of adjacent vertebrae. Spon-
dylosis is most often reported in the thoracic, lumbar, and lumbo-
sacral spine of middie-aged to old male dogs. Spondylosis in the
caudal cervical spine of Doberman pinschers and in the lumbosa-
cral spine of all dogs may be associatedwith, but is not diagnostic
of, cervical or lumbosacral instability. Spondylosis may be found
adjacent to degenerative,ventrally protruding, or normal interver-
tebral discs and may be associatedwith a site of spinal instability,
but often its etiology is idiopathic. Radiographically,the new bone
formation is best seenventral to the affected vertebrae. but it mav
occur along the lateral and dorsolateral margins ofvertebral bodies.

Figure 9-9. Sagittalmagnetic resonanceimage of the lumbosacralregion

showinglow-signal/b/ack)spondylosisat L7-S1 and a low signa mass (herniated
degenerateddi scand fi brousti ssue)i n the vertebralcanalat L7-S 1.

Figure 9-1O. SagittalreformattedCT of L7-S1.Thereis a herniated
disc
andfibroustissuein theventral
halfof thespinal
cord.
The dorsolateral new bone may extend to the intervertebral foram-
ina, but it does not usually encroach on the spinal cord. Spon-
dylosis deformans is often clinically insignifi cant.3'-3s
It has been reported that excessmotion between adjacent verte-
bral bodieseither in a lateralor in a dorsoventraldirection may
result in a degenerative,somewhat interdigitating "sawtoothed pat-
tern" on adjacent vertebral end plates. A1so, a localized area of
increasedbone opacity called a "bone island" may occur within a
vertebral body as a result of clinicaily insignificant, abnormal bone
remodeling at that site.31
Degenerative joint disease of diarthrodial joints of the spine
produces irregularly shaped articular processes(Fig. 9-1,2). Similar
bony proliferation in and around the interarcuate foramina located
between adjacent dorsal spinous processesof adjacent vertebrae
(Baastrup'ssyndrome) may mimic articular degenerativejoint dis-
ease;an attempt should be made to distinguish betrveenthese.The
actual clinical significance of either condition is often difficult
to assess.36
I Metabolic or metabolic-like
I conditions of the vertebrae
Hypertitaminosis A may result in an ankylosing bony proliferation
along the arches and lateral aspects of the bodies of the cervical
F i g u r e 9 - 1 1 . S p o n d ylo siso f th e lu m b a ra n d lu m b o sa cral
l e w b o n eh a s fu se din th is p a tie nt.
s p i n e .S o m eo f t h e ve n tr a n
TheV ertebrae-C ani ne
and Feline l03
vertebrae. In addition, bony proliferation may occur on thoracic
and lumbar vertebrae, on some of the long bones, and around
limb joints. Hypervitaminosis A, or "dietary osteodystrophy,"has
been reported primarily in cats and may result in progressive
mechanical obstruction to movement.36, 37
Mucopolysaccharidosisis a lack of degradation of acid muco-
polysaccharides before their excretion fiom the body. Multiple
bony changes may be seen, including tall, partially fused cervical
vertebrae; irregularly shortened and misshapen thoracic vertebrae;
partial fusion of lumbar vertebrae; widened intervertebral spaces;
and a seemingly widened spine owing to bony proliferation.3&3e
Hyperparathl.roidism, either primary or secondaryto nutritional
or renal problems, may result in a poorly mineralized and weak-
ened spine (Fig. 9-13). Abnormal spinai curvature and pathologic
fractures of the spine may occur. Osteopenia of the spine may also
occur as a result of senile osteoporosisand much less commonly
from disuse atrophy, pseudohlperparathyroidism, paraneoplastic
syndrome, Cushing's syndrome, hypothyroidism or hyperthyroid-
ism, and osteogenesisimperfecta. Congenital hypothyroidism may
also result in abnormaliy prolonged persistenceof the physes in
the vertebralbodies and shortenedvertebralbodies.t0,"
Osteopetrosisis an increasein bone opacity as a result of retarda-
tion of bone turnover, resorption, and^remodeling.The condition
is very uncommon, but has been reported in Dachshunds. Radio-
graphic findings include uniformly increasedbone opacity, without
I I 04 AXIALSKELETON
"#;'**..ffi
:,4.:g
lilalll:iii
. -:- -- :- :j
Figure 9-12. Degeneratvejoint diseaseof articularprocessesat T13-L1 (arrows).The joinl
spaceis irregular,and there are osteophyteson the artlcularprocesses.
distinction between cortical and medullary bone. Pathologic frac-
tures may occur. Although its origin is uncertain, the condition
may be congenital and familial, occurring as a recessivetrait.a2
I lnflammation of the vertebrae
Inflammatory diseaseof the vertebrae may be a result of spondyli-
tis, osteomyelitis, discospondylitis, or vertebral physitis. Spondylitis
is inflammation of a vertebra, not necessarilyassociatedwith sepsis.
Spondylitis infectiosa implies inflammation of the vertebrae as a
result of a specific pathogen. The canine parasite Spirocercalupi
may causea localized ventral vertebral body bony proliferation that
is not to be confused with idiopathic spondylosis deformans. In S.
Iupi infection, bony proliferation may occur across the ventral
surfacesof T8 to Tli, and an esophagealmass is often present.
Spondylitis is differentiated from the term spondylopathyin that
spondylopathy is any disorder of the vertebrae.a3
Vertebral osteomyelitis, or spondylopyosis,is a generai term for
sepsis or suppuration of a vertebra; radiographically, it manifests
as irregular, poorly marginated bone lysis and production on any
or all parts of one or more affected vertebra (Fig. 9-la). An
irregularly shapedperiosteal reaction is often present. Bacterial and
mycotic vertebral osteomyelitis may occur. Hematogenous infec-
tions are often the cause,but secondary contiguous infection from
migrating foreign bodies or other soft-tissue infection is possi-
b ] e . 4 3,4 4
Discospondylitis is inflammation or sepsisof the intervertebral
disc spaceand adjacent ends ofthe adioining vertebral bodies. The
hallmark radiographic sign of discospondylitis is symmetrical lysis
ofthe vertebralbody end plates (Fig.9-15). Areasofbone lysis or
- " "--:
;--:-'.-$f
l::rrriiil
t9ut_:l
of bone production (sclerosis) in the vertebral bodies adjacent to
the end-plate lysis are common. Spondylosismay develop from the
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.
Staplrylococcusaureus, Brucella species, Corynebacteriurn species,
Streptococcus canis, and Escherichiacoli have been reported as caus-
ative bacterial agents.Infections are often thought to occur second-
ary to hematogenousspread of bacteria. Discospondylitis is uncom-
mon in cats, but reported causative agents have included
Streptococcus,Actinomyces,and E. coli.a5-50
Vertebralphysifls is an infection of the vertebral body that radio-
graphically manifests as bone lysis of the caudal physeal region of
the affectedvertebral body, with sparing of the vertebral end plates.
Collapse of the caudoventral aspect of the affected vertebral body,
spondylosis developing from the caudal vertebral margins, and
spinal kyphosis may occur. The condition seemsto occur primarily
in young dogs. The infections are probably hematogenous in ori-
gin.sr
I Neoplasia of the vertebrae
Neoplasia,benign or malignant, may occur in the vertebrae.Benign
neoplasiais infrequent, with the most common tlpe being multiple
cartilaginous exostosis(MCE). MCE occurs in dogs that are
younger than 1 year of age, with the lesion enlarging during the
time of endochondral bone formation. The cartilaginous exostoses
radiographically appear as expansileeniargementsof spinous proc-
essesand of the dorsal laminae; when the latter is involved, this
may result in encroachment on the vertebral canal. Although un-
Figure 9-13. Lateralview of the lumbarspine of an African lion with
The overallopacityof the skeletonis de-
nutritionalhyperparathyroidism.
creased,and vertebraeare mi sshapen.

of the caudalspine.Thereis destruction
Figure 9-14. Osteomyelitis of two
vertebrae
andactivenewboneformationat severalsites.
common, malignant transformation of these lesions is a possibility.
In dogs, a hereditary basis for the condition has been suspected.
Feline MCE is very uncommon and is a somewhat different disease
than in the dog. In the cat, the condition occurs in young adults
subsequent to skeletal maturity, may have an association with the
feline leukemia virus, and produces lesions that rapidly enlarge.t'
Malignant vertebral neoplasms include primary neoplasms such
as osteosarcoma, chondrosarcoma, fibrosarcoma, myeloma, and
hemangiosarcoma. Osteosarcoma arises from the medullary part
of the bone. Malignant secondary vertebral neoplasms include
metastatic carcinomas such as anaplasticcarcinoma, prostatic carci-
noma, perianal gland carcinoma, mammary carcinoma, thyroid
carcinoma, and transitional cell carcinoma; and sarcomassuch as
osteosarcoma,hemangiosarcoma, fibrosarcoma, and undifferenti-
ated sarcoma. Osteochondroma is the only benign tumor of the
vertebrae.Most malignant primary vertebral neoplasmsreside
within one vertebra; malignant secondaryvertebral neoplasmsmay
reside within one or more vertebrae; benign neoplasms may occur
in one or more vertebrae. It has been reported that malignant
primary vertebral neoplasms occur with higher frequency in the
thoracic spine, and malignant secondary vertebral neoplasms in
the lumbar spine. Large breeds of dogs, such as German shepherds,
Standard Poodles, and Labrador retrievers, are more likely to have
vertebral neoplasms than are smaller breeds; on the average,this
occurs when they are about 7 years of age. Malignant primary or
secondary neoplasia may alter the shape of the vertebrae by de-
stroying bone, producing bone, or both (Fig. 9-16). The bone
destruction often affects the cortical bone of the vertebrae, and
there may be collapseofthe adjacentdisc space.A paraspinal,soft-
tissue mass may be present. Myeloma and hemangiosarcoma of
the vertebrae often produce "punched-outj' osteolytic-appearing
lesions in the vertebrae (Fig. 9-17). In contrast with discospondy-
litis, spinal neoplasia does not routinely result in symmetrical end-
plate lysis cranial and caudal to an intervertebral disc. Radiographi-
Figure 9-15. Brucel/adiscospondylitis in the thoracicspine (arrow).There is
adjacenlend-platelysisof the two affectedvertebrae.
The Vertebrae-Canineand Feline t05
cally, the differentiation of neoplasia from osteomyelitis may be
difficult if the tumor is producins bone.s360
The intervertebral foramen b".o-. enlargedwhen occupied
by extradural neoplasia,such as-u!meningioma or neurofibroma (Fig.
9-18). Although these neopiasms may occur at any location, they
most often invoive the cervical spine. It has been reoorted that
extraduraltumors may causebone lysisand bone producrion,the
presence and degree of which may be visualized better with CT
than with survey radiographs. The vertebral canal may appear
either widened or osteolytic as a result of intradural, intramedullary
neoplasiasuch as astroc)'tomaor ependymoma(Fig. 9-19).ss,et
I Trauma to the vertebrae
Fractures may involve any part of the spine, but the most common
sites are the vertebral body, the transverseprocess,and the spinous
process. Fracture of the vertebral body may be accompanied by
abnormal spinal alignment, especially when the fracture involves
the lumbar spine. Fractures may be accompanied by subtle nar-
rowing of the adjacent intervertebral disc space. Vertebrae may
appear smaller than normal owing to compression fractures. Be-
cause of the compacting nature of compression fractures, affected
vertebraeare often increasedin opacity (Fig. 9-20). Fracturesand
malunion fractures of vertebrae may result in innumerable dis-
torted shapes.Orthogonal views to determine the degreeof fracture
displacement should be taken. Horizontal beam radiography may
be needed to prevent unsafe manipulation of the spine.
Subluxation or luxation of the spine mav occur with or without
fracture. Subluxation may be accompanied by narrowing of the
adjacent intervertebral disc space.The spinal displacement may be
evident on one radiographic view, but less apparent on the orthog-
onal view, and again, caution needsto be observedduring radiogra-
phy so as not to make the lesion worse (Fig. 9-21).
I0 6 A X I A LS K E LE T O N

Figure 9-16. l\4etastaticneoplasia(squamouscell carcinoma).There is

osteol yti and
c osteobl astichange
c i n L3.

Figure 9-17. Lateralradiographof the midthoracicspine

g o m m u ltipe m y-
T herea r em u l t i p l ef o c a ll y ticle sio n sr e su ltin fr
elom a .

Figure 9-18. Lateralview of the lumbarspine showingan

enlargedintervertebralforamen ar L2-3, as a result of an
o vn e n ci l a nor r n {i h r n m r
 The Vertebrae-Canineand Feline lO7

Figure 9-19. Expansile-appearing widening of the verte-

bral canalof L4-5 secondaryto an astrocytomaof the spinal
co r d .

lgrrra -ii11rl,
'lu.t
r.:lll:
-e F- g

,,i€ll

Fi gure 9-2O. Lateralradi ographof the thorac ol umbar

spi ne show i ng an i ncreasedopaci ty,w edge-s haped,mal -
alignedT12 vertebralbody that has a compressionfracture.
I0 8 A X I A LS K E LE T O N
Figure 9-21, Lateral/A/ and ventrodorsaliBl radiographsof the caudallumbar
spine. A, There is a ventral subluxationand chip fractureat L6-7 8, The spine
aooearsnormalon the ventrodorsalview
References
1. Evans HE, Christensen GC: Miller's Anatomy of the Dog, 2nd ed' Philadelphia,
WB Saunders, 1979.
2. Watson AG. Stewart JS: Postnatal ossilication centers of the adas and axis in
miniature schnauzers.Am I Vet Res 51:264, 1990.
3. Dyce KM, Sack WO, Wensing CJG: Textbook of Veterinary Anatomy, 2nd ed'
Philadelphia, WB Saunders, 1987.
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
Vet Radiol Soc 9:21, 1968.
5. Morgan IR Bailey CS: Cauda equina slndrome in the dog: Radiographic evalua-
tion. J Small Anim Pract 31:69, 1990.
6. Morgan JR Bahr A, Franti CE, et al; Lumbosacral transitional vertebrae as a
predispoiing cause of cauda equina slmdrome in German shepherd dogs: 161 cases
(1987-1990).J Am Vet Med Assoc 202:1877,1993.
7. Larsen JS: Lumbosacral transitional vertebrae in the dog. J Am Vet Radiol Soc
18:3, 1977.
8. James CM, Lassman LR Tomlinson BE: Congenital anomalies of the lower spine
and spinal cord in Manx cats. i Pathol 971269,1969.
9. Bailey CS: An embryological approach to the clinical significance of congenital
vertebral and spinal cord abnormalities. J Am Anim Hosp Assoc II:426' 1975'
10. Coulter SB: Congenital anomalies ofthe spine. In Bojrab MJ (ed): Pathophysiology
in Small Animal Surgery. Philadelphia, Lea & Febiger' 1981, p 729.
11. Taneka T, Uthoff HK: The pathogenesis of congenital vertebral malformations'
Acta Orthop Scand 52:413,1981.
12. Bailey CS, Morgm lP: Congenital spinal malformations. Vet Clin North Am Small
Anim Pract 22'.985, 1992.
13. Wilson JW Kurtz Hl, Leipold HW, et al: Spina bifida in the dog. Vet Pathol
16:165, 1979.
14. Oliver IE, Lewis RE: Lesions of the atlas and axis in dogs. I Am Anim Hosp Assoc
9:304,1973.
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
A s s o c2 1 6 :1 1 0 4 ,2 0 0 0 .
16. Chambers JN, Betts CW: Caudal cervical spondylopathy in the dog: A review ot
20 clinical casesin the literature. J Am Anim Hosp Assoc 13:571' 1977.
17. Raffe MR, Knecht CD: Cervical vertebral malformation: A review of 36 cases.J
Am Anim Hosp Assoc 16;881,1980.
18. Trotter El, delahunta A, Geary JC, et al: Caudal cervical malformation: Malarticu-
lation in Great Danes and Doberman pinschers. J Am Vet Med Assoc 168:10, 1976.
19. Sharp NJH, Cofone M, Robertson ID, et al: Computed tomography in the
evaluation of caudal cervical spondylonyelopathy of the Doberman pinscher. Vet
Radiol Ultrasound 36;100,1995.
20. Lincoln JD: Disease of the spine. Vet Clin North Am Small Anim Prcct 22:923,
1992.
21. Denny HR, Gibbs C, Holt PE: The diagnosis and treatment of cauda equina
lesions in the dog. J Small Anim Pract 23:425, 1982.
22. Oliver JE, Selcer RR, Simpson S: Cauda equina compression from lumbosacral
malarticulation and malformation in the dog. J Am Vet Med Assoc 173:2, 1978.
23. Tarvin G, Pratat RG: Lumbosacral stenosis in dogs. J Am Vet Med Assoc 177:2,
1980.
24. Lang I: Flexion-extension myelography of the canine cauda equina. Vet Radiol
29:242,1988.
25. Mattoon JS, Koblik PD: Quantitative survey radiographic evaluation ofthe lumbo-
sacral spine of normal dogs and dogs with degenerative lumbosacral stenosis. Vet
Radiol Ultrasound 34i194, 1993.
26. Adams \4rH, Daniel GB, Pardo AD, et al: Magnetic resonance imaging of the
caudal lumbar and lumbosacral spine in 13 dogs (1990 1993). Vet Radiol Ultrasound
36:3, 1995.
27. Hathcock JT, Pechman RD, Dillon AR, et al; Comparison of three radiographic
contrast procedures in the evaluation of the canine lumbosacral spinal canal. Vet
Radiol 29:4, 1988.
28. lones JC, Wilson ME, Bartels JE: Review of high resolution computed tomography
and a proposed technique for regional examination of the canine lumbosacral spine.
Vet Radiol Ultrasound 35:339, 1994.
29. Jones JC: Computed tomographic anatomy of the canine lumbosacral spine. Vet
Radiol Ultrasound 36:260, 1995.
30. Feeney DA, Evers P, Fletcher TR et al: Computed tomography of the normal
canine lumbosacral spine: A morphologic perspective. Vet Radiol Ultrasound 37:399,
1996.
31. Morgan lP: Spondylosis in the dog: Its radiographic appearance.J Am Vet Radiol
Soc 8:17. 1967.
32. Wright JA: A study ofvertebral osteophyte formation in the canine spiae: I. Spinal
survey. J Small Anim Pract 23:697, 1982.

Figurc 9-22
33. Wright JA: A study of vertebral osteophlte formation in the canine spine; II.
Radiographic survey. J Small Anim Pract 23:747,1982.
34. Karkkainen M, Punto LU, Tulamo RM: Magnetic resonance imaging of canine
degenerativelumbar spine diseases.Vet Radiol Ultrasound 34:399,1993.
35. Morgan JP, Miyabayashi T: Degenerative changes in the vertebral column of the
dog: A review of radiographic findings. Vet Radiol 29:72, 1988.
36. Morgan JP: Radiology in Veterinary Orthopedics. Philadelphia, Lea & Febiger, 1972.
37. Riser WH, Brodey RS, Shirer IF: Osteodystrophy in mature cats: A nutritional
disease.I Am Vet Radiol Soc 9:37, 1968.
38. Cowell KR, lezyk PF, Haskins ME, et al: Mucopolysaccharidosis in a cat. I Am Vet
Med Assoc 169:3, 1976.
39. Haskins ME, Jezyk PR, Desnick RJ, et al: Mucopolysaccharidosis in a domestic
short-haired cat: A diseasedistinct from that seen in the Siamesecat. J Am Vet Med
Assoc 175:4,1979.
40. Smith HA, lones TC: Veterinary Pathology,3rd ed. Philadelphia,Lea & Febiger,1966.
41. Saunders HM, lezyk PF: The radiographic appearance of canine congenital h)?o-
thyroidism: Skeletal changeswith delayed treatment. Vet Radiol 32:171, 1991.
42. Riser WH, Frankhauser R: Osteopetrosis in the dog: A report of three cases.J Am
Vet Radiol Soc 1l:29, 1970.
43. Dorland NW; Dorland's Illustrated Medical Dictionary, 29th ed. Philadelphia, WB
Saunders, 2000.
44. lohnston DE, Summers BA: Osteomyelitis of the lumbar vertebrae in dogs caused
by grass-seedforeign bodies. Aust Vet J 471289,1971.
45. Walker TL, Gage ED: Vertebral osteomyelitis, discospondylitis, and cauda equina
slmdrome. In Bojrab Ml (ed): Pathophysiology in Small Animal Surgery. Philadelphia,
Lea & Febiger,1981.
46. Hurov L, Troy G, Turnwald G: Discospondylitis in the dog: 27 cases.J Am Vet
Med Assoc 173:3,1978.
47. Koregay JN, Barber DL: Discospondylitis in dogs. J Am Vet Med Assoc 177:4, 1980.
48. LeCouteur RA, Child G: Diseasesof the spinal cord. In Ettinger S (ed): Textbook
of Veterinary Internal Medicine. Philadelphia, WB Saunders, 1989.
49. Malik R, Latter M, Love DN: Bacterial discospondylitis in a cat. J Small Anim
Pract 31:404.1990.
Figure 9-23
The Vertebrae-Canineand Feline l(l9
50. Moore MP: Discospondylitis.Vet Clin North Am 22:1027,1992.
51. Jimenez MM, O'Callaghan MW: Vertebral physitis: A radiographic diagnosis to be
separated from discospondylitis. Vet Radiol Ultrasound 36:188, 1995.
52. Owens JM, Biery DN; Radiographic Interpretation for the Small Animal Clinician,
2nd ed. Baltimore, Williams & Wilkins, 1999.
53. Luttgen Pl, Braund KG, Brawner WR, et al: A retrospective study of twenty-nine
spinal tumors in the dog and cat. J Small Anim pract 21:213,1980.
54. Morgan lP, Ackerman N, Bailey CS, et al: Vertebral tumors in the dog: A clinical,
radiologic, and pathologic study of 61 primary and secondary lesions. Vet Radiol
2l :5,1980.
55. Wright JA, Bell DA, JonesDG: The clinical and radiolosic features associatedwith
s pi nal tum or s i n thi r ty dogs . I Sm al l Ani m Pr ac t20:4b1,1979.
56. Osborne CA, Permen V, Sautter JH, et al: Multiple myeloma in the dog. J Am Vet
M ed As s oc 153:1300,1968.
57. Bartels lE, Cawley Al, McSherry BJ, et al: Multiple myeloma (plasmacltoma) in a
dog. J Am Vet Radiol Soc 13:36,1972.
58. Jergens AE, Miles KG, Moore FM: Aly?ical lytic proliferative skeletal lesions
associatedwith plasma cell myeloma in a dog. Vet Radiol 3l:262, 1990.
59. Drost Wl Love NE, Berry CR: Comparison of radiography, myelography and
computed tomography for the evaluation of canine vertebral and spinal cord tumors
in sixteen dogs. Vet Radiol Ultrasound 37:28,1996.
60. Thomas WB, Daniel GB, McGavin D: Parosteal osteosarcoma of the cervical
vertebra in a dog. Vet Radiol Ultrasound 38:120, 1997.
61. Suter PF, Morgan JP, Holliday TA, et al: Myelography in the dog: Diagnosis of
tumors of the spinal cord and vertebrae. J An Vet Radiol Soc 12:29, j.97ir
mffiQuestions
1. Normally, there are seven lumbar vertebrae in the dog. How
might one explain what appears to be eight lumbar vertebrae
on a radiograph?
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)?
Answers begin on page 727.
ffi CHAPTER
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
cause that results in protrusion of the disc or disc material into
the vertebral canal, compressing the spinal cord or spinal nerve
roots.l 3 Although other "diseases"affect the intervertebral disc, we
consider only disc protrusion in this chapter.
Intervertebral disc diseaseaffectsall breeds of dogs; the chondro-
dystrophic breeds are over-rePresented,with the highest prevalence
in the Dachshund (45o/o-65o/o of affected dogs).'a Beagles'Cocker
spaniels, Toy Poodles, and Pekingesealso have a high prevalence.
Doberman pinschers afflicted with cervical vertebral instability-
malformation,t German shepherds,uand mixed-breed dogs also
develop intervertebral disc disease.
Neural signs of intervertebral disc disease generally manifest
after 3 years of age; however, in chondrodystrophic breeds, disc
degeneration begins before 1 year of age. No gender predilection
has been identified.' Common sites of disc protrusion are Tl2-13
and T13-L1 in the thoracolumbar region, and C2-3 and C3-4 tn
the cervical region.'' 3 Although clinical signs of intervertebrai disc
diseaseare uncommon in cats, cervical disc degenerationfrequently
occurs in cats older than 6 years of age.''t
Suspected intervertebral disc disease is one of the most im-
portant indications for radiographic evaluation of the vertebral
column of small animals. Accurate radiographic examination can
establish the presenceand severity of disc disease,allowing clini-
cians to determine prognosis and proceed with treatment. Because
many radiographic signs of disc diseaseare subtle and other spinal
conditions may be the causeof clinical signs, accurateradiographic
interpretation requires a thorough knowledge of anatomy, physiol-
ogy, and neurology.
Radiology is also valuable for the assessmentof animals with
neoplastic, inflammatory, congenital, and degenerativeconditions
of the spinal cord.
I Anatomic and physiologic
I considerations
The intervertebral disc is composed of a tough outer annulus
fibrosus, which contains the gelatinous, inner nucleus pulposus
(Fig. 10-1).28The annulushas severalconcentricfibrocartilaginous
layers, which are firm1y attached to adjacent vertebral end plates
and centra.l't The nucleus pulposus is eccentricallylocated;thus,
the annulus is thin dorsally and thick ventrally. This partially
explains the tendency for dorsal herniation of diseased discs. A
mi*tn." of proteoglycans, collagen fibers, mesenchymal cells' and
water makes up the normal jelly-like nucleus. Only the outermost
layers of the annulus have a neurovascular supply.t The disc forms
a cartilaginous joint between vertebral segments (excluding C1-2
and the sacrum) and thus functions as a hydraulic shock absorber.
Shock absorption is dependent on a hydrated, deformable nucleus
and an intact, elastic annulus.T
The longitudinal ligaments of the vertebral column provide
rt o
dorsal and ventral support for the intervertebral discs.sThe dorsal
longitudinal ligament joins the dorsum of the vertebral centra and
lies on the floor of the vertebral canai (see Fig. 10-l). In the
cervical region, the dorsal ligament is wide and thick; consequently,
lateral extrusion ofdisc material and radiculopathy (root signature)
are more common than dorsal extrusion and severecord compres-
sion.e In comparison, the dorsal longitudinal ligament is thin in
the thoracolumbar region, predisposing to dorsal protrusion and
cord compression. The ventral longitudinal ligament spans the
ventral surface of the vertebral coiumn, offering ventral support.
The intercapital ligaments are short, transversefibrous bands that
lie ventral to the dorsal longitudinal ligament, joining the rib heads
betrveenT2 and T11. Theseligamentsbuttressthe dorsal part of the
annulus cranial to T11 and help resist dorsal disc protrusion.s'10'rr
The vertebral canal of the dog is crowded, and the epidural space
is small. Thus, the canine spinal cord is subject to compression by
epidural masses, for example, disc protrusion. The Dachshund,
compared with the German shepherd dog, has a very high spinal
cord-to-canal ratio-that is, a small epidural space." Possibly,this
explains the severeneurologic signs seenin the Dachshund follow-
ing disc protrusion. Owing to alarger epidural space,small protru-
sions causing minimal cord compressions are less significant in
large-breed dogs. The ratio of spinal cord to vertebral canal is
Iowest in the cervical area; therefore, neurologic signs tend to be
Iessseverewith cervicalversusthoracolumbardisc orotrusion.3'e'11
The spinal cord and the spinal nerve roots lie within the bony
vertebral canal, which consistsof the individual vertebral foramina
(see Fig. 10-1). Paired intervertebralforamina serve as windows,
allowing exit of the spinal nerves and blood vessels.The meninges
surround the spinal cord and consist of the inner pia-arachnoid
membrane and the tough, outer dura (Fig 10-2). Tha cervical and
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,
terminates at the conus medullaris, near the level of L6. In small-
breed dogs, the cord ends caudal to L6, and in large breeds,cranial
to L6l this is an important factor for consideration when lumbar
subarachnoid puncture is to be performed. In the cat, the spinal
cord extends slightly beyond L6."
The spinal cord segmentsand vertebrae have the same numeric
designation (with the exception of cord segment C8), but the
location of each cord segment is rarely found within the corre-
sponding vertebra.l0The reason is twofold. First, the spinal cord is
shorter than the vertebral column because of differential fetal
growth rates. Second,many of the cord segmentsare shorter than
the vertebral segments.Therefore, cord segmentsare located cranial
to their respective vertebrae, and the spinal nerves must course
caudally and obliquely within the vertebral canal a short distance
before exiting via the intervertebral foramina. The collection of
spinal nerve roots in the lumbosacral region is known as the cauda
equina. These nerves, like the spinal cord, are subject to compres-
sive injury causedby disc protrusion.
 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

Figure 10-1. Anatomiccomponentsof a typicallumbarvertebra(A) and an intervertebral

disc /B/. (Adaptedfrom EvansHE, ChristensenJC: Miller'sAnatomy
o f t h e D o g ,2 n d e d . Ph ila d e lp h ia
WB , Sa u n d e r s,1 9 7 9 .)

The subarachnoid space lies between the arachnoid membrane
and the pia mater, which surrounds the spinal cord and spinal
nerve roots. Cerebrospinalfluid (CSF) fills the subarachnoidspace,
displacing the lacy, arachnoid membrane peripheraily against the
dura. The spinal subarachnoid space begins at the foramen mag-
num, where it communicates with the subarachnoid space of the
cranial cavity; it ends caudally at the filum terminale, near the
lumbosacral junction.8 The central canal of the spinal cord is filled
with CSF and communicates rostrally with the ventricular system.
In most dogs, the central canal terminates blindly at .the conus
medullaris; however, in some dogs, the canal is continuous with
the lumbar subarachnoid space.
and mineralization of the nucleus pulposus.The annulus fibrosus
also degeneratesand loses its capacity to contain the diseased
nucleus. Consequently, the weakened disc cannot withstand dy-
namic forces applied by the vertebral column, and protrusion
ensues.Type I protrusion follows chondroid degeneration and is a
result of extrusion of dehydrated nuclear material into the vertebral
canal. Fibroid degeneration is frequently recognized in old, non-
chondrodystrophic breeds and is characterizedby fibrous metapla-
sia of the nucleus pulposus. The annulus fibrosus may stretch,
partially rupture, or hlpertrophy and protrude into the vertebral
canal, thereby compressing the cord. Type I lesions tend to be
acute, forceful extrusions that cause compressivemyelopathy and
severe neurologic signs.' Tlpe II lesions are associated with a

I Pathophysiologic chronic, progressivecourse and mild neurologic signs, even though

I considerations
The terminology used to describe intervertebral disc lesions is
confusing and inconsistent.t Protrusion is a nonspecific term that
defines any discal mass that is impinging on the spinal cord or
spinal nerve roots. Herniation (bulging disc) implies that the nu-
cleus pulposus is causing a bulge by stretching an intact annulus.
An extruded, prolapsed, or blown-out disc is one in which the
nucleus has broken through the annulus into the epidural space.
Unfortunately, these terms are often used interchangeably. The
distinction between herniation and extrusion is not always evident
with conventional radiography; therefore, the term disc protrusion
is preferred.
Two forms of disc degeneration have been described, which
result in different types of protrusion.l,' Chondroid degeneration
occurs in chondrodystrophic breeds and is typified by dehydration
significantcord compressionmay be present.eThis is becausethe
spinal cord can better sustain the slow deformation of a type II
lesion than it can the explosiveconcussionand compressionof a
type I lesion.'Z
Spinal cord comprtissionby protruded discscausesa closedtype
of injury that alters cord function and structure.T'e' rr' I1 16fivo
main factors contribute to the pathologic changes of closed cord
injury: (1) mechanicaldisruption causedby compressionand con-
cussion,and (2) chemical and vascular changeswithin the cord.
Severity depends on the dynamic force, duration and amount of
compression,and degreeof concussionassociatedwith the initial
injury. Spinal cord compression restricts the local arteriovenous
supply, and severearterial compromise may causeinfarction. Ische-
mia of the spinal cord induces the releaseof potent vasoactive
amines,including norepinephrine,serotonin,and dopamine,which
leadsto hematomyelia and myelomalacia.rn
II2 A X I A LS K E L E T O N

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,

Figurc 104. Patternsof intervertebral disc miner-

al i zati on.
A , C ontarned, mi neralze d dts c materi alat
mu tiple sites (arrows)in a dog without neurologic
si gns.B and C , Mtneral i zed, extrudeddi s c stn a dog
with cervicalpain.The intervertebral foramenat C2-3
(B /i s smal l ,and di ffusel ymi neral i z ed
di s c materi ai s
causi ngsl i ghropaci tyw i thi nrhe cara tarrow r. -l -es e
fi ndi ngsare typi calof an acute prol aps e.C , The
bLTto^l i ke,r nerai zeoo sc ma-er i alaTC 6 7 i s c o^-
sistent with chronic prolapse(closedarrows).Note
the narrowdi scspaceat C 6-7and mi neral i z ed mate-
rial remainingwithin the disc /openarrow).D, Miner-
alized,empty annulusfibrosus (stnatedarraw) Iol
l ow i ng extrusi on of the nucl eus pul pos us /open
arrow).E, Falsemineralization at C7-T1is causedby
overlapof the first rib pair (arrows).The intervertebral
di scspaceat C 7-T1i s normal l ynar row erthan i t s at
adtacentspaces.
II4 A X I A LS K E LE T O N

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
Pia mater
Cord
Ventral
subarachnoid
space
Figure 10-g. Lumbarpuncture causesmechanical damageto the cord A,
CJnpression of the spinalcord by resistance of the toughdura B, The
compression is releasedas the needletip passesthroughthe dura,entenng
thecord.Horizontal movement shouldbe minimlzed to avoidcorddamage C
Theneedleis retracted (1-2mm)afterit hasreached
slightly theventralaspect contrast medium, reducing subarachnoid opacification in nonde-
of the vertebral canal,reducingthe chanceof epiduralinjectionlReprinted pendent regions. On the ventrodorsal projection, dependency
fromWidmerWR, Blevins WE:Veterinary myelography: A reviewof contrast
media,adverseeffects,andtechnique. J Am AnimHospAssoc19:755-760, causes contrast medium to
1991.)
bevel in the dorsal subarachnoid spaceis technically more difficult'
but causes less mechanical damage to the spinal cord (see Fig'
10-7C). Transmedullary passage of the needle is necessary for
ventral subarachnoid puncture and invariably damages the cord'
This can be minimized by keeping the stylet in place and avoiding
horizontal movement of the needle during puncture. However, it
has been shown that the dorsal aspect of the cord is compressed2
to 3 mm ventrally as the needle tip is resisted by the tough dura
(Fig. 10-8).'z8Therefore,the cord can be injured by compression
ur *"ll u. by mechanical disruption by the needle. Obviously' with
dorsal needle placement, there is compression only of the cord'
With either ventral or dorsal puncture' correct needle placement
should be confirmed by fluoroscopy or radiography after a test
injection of contrast medium; otherwise, intramedullary injection
may occur. Dorsal subarachnoid entry is technically superior be-
cause only one puncture of the subarachnoid space is made, thus
decreasingthe likelihood of extradural leakageof contrast medium'
Regardlesiof the approach used, multiple needle punctures should
be-avoided because the risk of epidural leakage is increased with
eachattempt.2r
lnterpretive prinGiPles
Knowing the relationship of the spinal cord to the meninges'
epidurafspace, and vertebral canal is essentialfor accurate myelo-
giaphic interpretation (see Fig. 10-2). The normal myelogram is
iypiA.A by a lharply marginated, thin column of contrast medium
in- the subarachnoid space (Fig. 10-94 and B)." " Small-breed
dogs and cats (see Fig. 10-9C and D) tend to have relatively large
cor"ds, and u. u t"t.tlt, a thin contrast medium column'" The
ventral aspect of the epidural (extradural) spaceis normally wide
in the caudal cervicai region, giving the false impression of cord
displacement.The dorsal aspectof the subarachnoid spaceis widest
at ihe Ct-z level and tends to be wider than the corresponding
ventral aspect of the subarachnoid space in the thoracolumbar
region. Normal epidural soft tissues cause a filling defect in the
ve"ntralaspect of the contrast medium column ar C1-2 and should
not be confused with an extradural lesion. Smaller filling defects
often seen dorsal to the remaining cervical discs are caused by
hlpertrophy of the iigamentum flavum or the annulus fibrosus'
Clinically significant subarachnoid filling defects should be accom-
panied by thinning of the opposite aspect of the contrast medium
column or evidence of cord compression. The thoracic cord lacks
an intumescence and is smaller than the cervical and lumbosacral
segments. Although the canine spinal cord terminates at L5-6,
the contrast medium-filled dural sac often extends beyond the
lumbosacral junction (see Fig. 10-78).'z|
The abnormal myelogram is characterizedby changesin the size
and location of the subarachnoid contrast medium column, and in
the width and opacity of the spinal cord. Myelographic lesions
can be grouped into the following patterns: extradural lesions,
intradural-extramedullary lesions, intramedullary swelling, and in-
tramedullary opacification(Fig. 10-10 and Table 10-1).2''ro:z
Several technical factors affect myelographic quality and inter-
pretation (Fig. 10-11).'?6Air bubbles cause circular or oval filling
defects that are potentially confusing; however, their location is
usually variable on subsequentradiographs." Subdural leakagemay
occur if the needle bridges the subdural and the subarachnoid
spaces,causing irregular margination and poor filling of the con-
trast medium columns. Epidural leakageof contrast medium
should be avoided becauseit adds unwanted opacity, obscuring the
subarachnoid contrast column.2l Gravity affects the distribution of
pool cranially, thereby reducing the
opacity of the caudal cervical subarachnoid space. The opposite
situation occurs with the dorsoventral projection; therefore, both
projections should be obtained routinely. On the lateral projection,
contrast medium pools cranially and caudally to the thoracic re-
gion. The effect of pooling can be overcome by elevating the rear
and forequarters of the animal, filling the thoracic subarachnoid
space. Pooling becomes more of a problem with hyperosmolal,
high-iodine-content contrast media.26
A "canalogram" occurs when the needle shaft is placed in the
central canal or when the central canal communicates with the
subarachnoid space at the level of the conus medullaris (Fig.
10-l2A).2' In the former instance, contrast medium is presumed
to leak back along the needle, especially during rapid injection."
Canalograms are most likely to occur when puncture is made at
L4-5, where the cord-to-vertebral canal ratio is large. The presence
Table 1O-7. Diagnostic possibilities associated with
myelographic patterns
Pattern Diagnosis
Extradural lntervertebraldisc protrusion
Ligamentoushypertrophy
Hematoma/hemorrhage
Neoplasia(vertebralor epiduralsoft tissue)
VertebraI fractureldislocation
lntradural- N e o p l a s i a( n e u r o f i b r o m a ,
extramedullary neurofibrosarcoma, and meningioma)
Granuloma
S o i n a lc o r d e d e m a
Intramedullary
swelling Neoplasia(neural,metastaticdiscretecell,
e . 9 . ,g r a n u l o m a t o u s
meningoencephalitis)
lschemicmyelopathy
lntramedullary Myelomalacia
opacification Hematomyelia
Normal Degenerativemyelopathy*
lschemicmyelopathy
Myelitis
Meningitis
*lt is the authors' opinion that spinal cord size may be decreased in dogs
with degenerative myelopathy; howeveq this has not yet been proved by
sci enti fi c i n vest i g ati o n.
 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 l17

:ie
4.,.

-;..-- .
",t-;
*l"-:
a,..,ll
irtti$

'llilrl

Figure 1O-9. Normalcervicalmyelogram.A, In a dog, on the lateralradiograph. the contrast

m e d i u mc o l u m n sar e wid e cr a n ia lly a n d th in ca u d a lly. So ft ti ssuesi dorsall ongi tudi nall i gament
or annulus)normallycausethinningof the ventralsubarachnoid space cz-3 (openblack arrow)
and should not be confusedwith disc prolapse.Smallerindentations/smal/white arrows) are
also seen in normaldogs.The epiduralspace is widest dorsalto C6-7 (closedblackarrows).B,
I n a d o g , o n t h e v e n tr o d o r sar a l d io g r a p ha, se r p e n tin esu b arachnoifidl l i ngdefecti s causeooy
t h e b a s i l aar r t e r yC. o n tr a stm e d iu mco lu m n sa r ea lsowid e rcrani al l y. N otethe poorsubarachnoj d
f i l l i n gi n t h e c a u d alce r vicarl e g io n wh
, ich is d u e to th e e ffect of dependency. C and D , In the
cat, the spinalcord is relativelywide and occupiesa largepercentageof the vertebralcanal,As
a result, the contrast medium columns are thin and conform closely to the marginsof the
v e r t e b r acl a n a l g, i v i n ga fa lseim p r e ssio o n f co r dswe llin g .
II8 A X I A LS K EL E T O N

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

.i A ^-\lHifl[?^ Figurc 1O-1O. Classification of myelographiclesions.A, Normal. B, Extradural.The contrast m6dium

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

F i g u r e 1 0 - 1 4 . T y pe ld isc p r o la p sewith in tr a m e d u lla rpyattern./, Lateralmyel ogram. Thereare i ntramedul l ary

sw el l i ngand thi n contrastmedi umc ol umns
larrows)al f11-12. B, Ventrodorsalmyelogramof dog in A. The cord is wide at T11-12; note axralshift of the right contiast medium column
larowsl. which
n d i c a t e sl a t e r a l i z a tioonf th e p r o la p seln
. th is in sta n ceth, e surgeonmay el ect to performa ri ght hemiami nectomy.Intervertebral di sc prol aps eat T11-12w as
confirmedat surgery.C, With severe intramedullaryswelling,the contrast medium columns may be totally obliterated(arrowheads), ru.[ing the extradural
c o m p o n e not f t h e l e s io n .In te r ve r te b rdaisc l p r o la p sea t L 2 - 3was confi rmedat surgery.

medullary swelling, the contrast medium column is thin and dis-
placed abaxially (Fig. 10-lM and B). In some instances, severe
srvellingmay completely obliterate the subarachnoid space(seeFig.
10-14C). Evidenceof intramedullary swelling is typically visible on
Iateral and ventrodorsal radiographic projections. Compensatory
erlradural compression of the cord causes focal intramedullary
sw'elling (shorter length than intramedullary swelling) on a single
radiographic projection (usually the ventrodorsal), and extradural
signs of disc protrusion are seenon the orthogonal projection. In
some instances,acutely extruded disc material may dispersearound
the cord and cause a subarachnoid filling defect that mimics cord
srvelling.36
If intramedullary swelling is present and there are no obvious
etradural signs, careful scrutiny of the myelogram may identifii
the site of disc protrusion. Slight axial deviation of the contrast
medium column at the site of cord swelling suggeststhe site of an
ertradural discal mass (see Fig. 10-148). This important clue is
often found on only one radiographic projection, but can help
determine the site for surgical exploration and decompression.It
should be kept in mind that hemorrhage from rupture of the
r-entral vertebral veins is a complication of acute disc diseaseand
may cause an extradural mass lesion. Whenever there is doubt
about the location of disc protrusion on the myelogram, the survey
radiographs should be re-evaluatedto be certain nothins has been
overlooked.
Technical considerations play an important role in the myelo-
graphic diagnosis of intervertebral disc disease.Radiographs made
immediately after rapid injection of contrast medium may enhance
the extradural component of disc protrusion and the extent of cord
swelling.a'" The use of oblique radiographic projections should be
considered on every myelographic study because they frequently
provide useful information. If disc material is located significantly
lateral to the ventral midline, the lateral and ventrodorsai radio-
graphs will show only cord swelling, whereas in oblique radio-
graphic projections (VL-DR and VR-DL) an extradural pattern will
be seen(Fig. 10-15). In some instances,both left and rlght lateral
radiographic projections are needed for accurate identification of
an extradural lesion.17
The gradual onset of tlpe II disc protrusion tends to minimize
cord swelling, resulting in an extradural myelographic pattern (Fig.
10-16). Chronic changes,including hlpertrophy of the annulus
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
of the spinal cord ("hourglassappearance").Type II protrusion is
part of the cervical vertebral malformation-instability (wobbler)
and lumbosacral stenosis-instability (caudal equina) syndromes of
large-breeddogs.''u
Diagnosisoflumbosacral disc protrusion presentsa specialprob-
1em to the radiologist. Although disc space narrowing, end-plate
scierosis,and spondylosisdeformansare associated with L7-Sl disc
protrusion, these changescan also occur in asymptomatic dogs.6In
addition, some dogs with L7-Sl protrusion have no radiographic
changes.ttLateral radiographic projections of the lumbosacrum in
both flexion and extension help in the evaluation of the dynamics
of lumbosacral instability, but results are often misleading.uRadio-
graphic contrast procedures routinely used to evaluate the lumbo-
sacral region include flexion-extension myelographf8 and epidu-
rography.3eMyelography may reveal evidence of disc protrusion,
providing the dural sac extends beyond the lumbosacral joint and
the myelogram is technically adequate.
Epidurography is performed by placing a spinal needle into the
vertebral canal between 53 and C3 and injecting contrast medium
into the epidural space.n0Dorsal displacement of the ventral epi-
dural space and complete obstruction to cranial flow of contrast
medium are the most consistentepidurographic findings of lumbo-
sacral stenosis(compression).a0 However, the normal contour of
the epidural space, unlike the subarachnoid space, is undulating
and subject to misinterpretation. Myelography should always pre-
cede epidurography because the latter obscures the subarachnoid
space.
Computed tomography
Computed tomography (CT) and CT myelography are useful when
conventional myelography does not clearly demonstrate a suspected
extradural lesion causedby disc protrusion (Fig. 10-17).ar'4,Be-
cause the contrast resolution of CT is suoerior to that of conven-
tional radiography, extradural compressivelesions causedby lesions
other than disc protrusion (ligamentous hypertrophy, hematoma,
tumor, etc.) can be identified. Cord swellins and intervertebral
foraminal changesare accurately diagnosed with CT myelography,
especiallywhen there is minimal subarachnoid distention. In Do-
berman pinschers with caudal cervical vertebral malformation-
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
iannot be obtained with conventionalradiography'a3 High-resolu-
tion CT provides excellent spatial resolution and image contrast
and is used to diagnoselesions of the cauda equina of human
beings. A technique using this modality has been proposed for
evaluationof the caninelumbosacralregion'aa
I Spinal cord diseases
Selectedconditions of the spinal cord that are amenable to myelo-
graphic evaluation are consideredhere. Although they are im-
portant diseases,conditions such as myelitis, meningitis, and de-
generative myelopathy are not included because they rarely are
accompanied by myelographic changes.
Spinal cord neoplasia
Tumors affecting the spinal cord may have intramedullary or extra-
medullary origtn. Intramedullary tumors are located within the
cord and cause cord swelling and disruption of neural pathways'
They are primary, developing from neural elements' or they are
metastatic. Extramedullary tumors arise from within the meninges
(intradural) or from any tissue found within the vertebral column
(extradural), including the vertebrae. Extradural and intradural-
extramedullary tumors involve the cord secondarily, causing com-
pression. Discrete cell tumors, like lymphosarcoma' are difficult to
ilassify because their sites of origin are usually unknown and
becausetheir locations vary.
Intramedullary tumors are relatively uncommon in the dog and
cat. Glial cell tumors, including astrocytomasand oligodendroglio-
mas, are the most common primary neoplasmsof the spinal cord
in dogs." Ependymomasand medulloepitheliomashave also been
reported and arise from the neuroepithelium.a6'a7 Lymphosarcoma
is the most frequent intramedullary tumor of cats' Intramedullary
spinal cord metastasis is seldom diagnosed in dogs and
cats-lymphosarcoma and hemangiosarcomaare the predominant
cell types.as"Primary" lymphosarcomaof the cord (i'e., no evi-
dence of extraneural involvement) has been reported in dogs.on
Extradural tumors are the tumors most commonly affecting the
soinal cord. These tumors lie within the vertebral canal and include
vertebral-origin osteosarcomas, myelomas,lymphosarcomas,me-
ningiomas, and metastatictumors. Intradural-extramedullarytu-
mors are locatedwithin the dural sheath,and neurolibrosarcomas'
meningiomas,and lymphosarcomasare the predominant cell type.
Unfortunately, the clinical presentation of animals with spinal
cord tumors often mimics that of disc protrusion and other non-
malignant causes.Pain and neural dysfunction are usually present.
Although gradual onset is expected with intramedullary tumors,
so-. unirnul, may manifestacutesigns.a5'at CSFanalysisperformed
in conjunction with myelography may detect exfoliated tumor cells.
On myelography,intramedullary tumors causecircumferential cord
swelling that is characterized by attenuation of the contrast me-
dium column. This cord swelling is easily confused with that
associatedwith acute disc protrusion' Signs of disc protrusion
noted on surveyradiographs(narroweddisc space,cloudy interver-
tebral foramen, etc.) can help with diagnosis.Slow-growing cord
tumors may causesmoothly marginatedbone loss of the vertebral
canal.However,this sign is inconsistentand is often a retrospective
finding. Extradural tumors causecord compression,attenuationof
the contrast medium columns, and cord swelling, also similar to
that of disc protrusion. Similarly, intradural-extramedullary tumors
can mimic any other mass within the meninges (see Fig' 10-10
and Table 10-l).
Intramedullary cavitary disease
Conditions typified by cavitation of the cord parenchyma are o{len
included under the general classification of spinal dysraphism."'
This all-inclusive term relatesto failure of the neural tube to close'
Cavitaly diseasesof the cord reported in dogs and cats include
hydromyelia, syringomyelia, and myelomeningocele. Hydromyelia
pertains to dilation of the central canal and may be congenital or
acquired. Congenital hydromyelia is thought to be associatedwith
malformations of the ventricular system that cause altered CSF
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-
ated with infection, trauma, or neoplasia affecting the ventricular
system.s'Myelographically, hydromyelia is qpified as a wide, con-
trast medium-filled central canal (seeFig. 10-l2,4.).Filling usually
results from leakagearound the needle, but in some instances,the
dilation of the canal is so large that it is accidentally punctured
during a cerebellomedullary tap. Saccular or smoothly marginated
widening of the canal may occur. Clinical signs associatedwith
hydromyelia may result from dilation and loss of cord parenchyma
or from the condition causing the hydromyelia (e.g., feline infec-
tious peritonitis). Frequently, hydromyelia is an incidental finding
and is not accompaniedby clinical signs.
Syringomyeliarefers to cavitation of the cord parenchyma,which
may or may not communicate with the central canal.s0When there
is communication, contrast medium fills the cavitations and can
be seen on myelography. Howeveg it is difficult to distinguish
cavitation of the cord parenchyma from hydromyelia becausethe
cavitations tend to merge with the dilated central canal.'l Because
the cord parenchyma is directly affected,animals with syringomye-
lia frequently have clinical signs. Syringomyelia is over-represented
in Weimaraners.
Myelomeningocelesare associatedwith spina bifida and consist of
protrusion of the cord and meninges through a defect in the
vertebral arch.s' Close examination of survey radiographs often
reveals duplication or attenuation of the spinous processesof the
affected vertebra (see Chapter 9). Myelographically, there is dorsal
displacementof the meningealsac and the conus medullaris of the
cord. The meningeal sac is dilated and various abnormalities,
including hydromyelia and syringomyeiia, may occur cranial to the
myelomeningocele. Spina bifida frequently affects the lumbar and
sacral vertebrae and is common in the English bulldog and the
Manx cat.
Fibrocartilaginous embolism
Fibrocartilaginous embolism is a syndrome of acute infarction of
the spinal cord due to the releaseof small fibrocartilaginous emboli
from intervertebral discs, which lodge in the cord parenchyma.
Infarction and ischemia occur, and cord swelling may be present.
Thus, intramedullary swelling may be seenon myelography.In one
report,s2narrowing of the intervertebraldisc spaceassociatedwith
fibrocartilaginous embolism is described. However, frequently with
fibrocartilaginous embolism, no changesare seenwith radiography
and myelography,and imaging is used to rule out other conditions.
Nerve root neoplasia
Neurofibromas,neurofibrosarcomas, meningiomas,and schwanno-
mas are the primary neoplasmsthat involve the nerve roots. Neuro-
fibromas and neurofibrosarcomasarise from the nerve parenchyma,
whereas schwannomasare encapsulatedand distinct from the
nerve.s3Meningiomas originate from the adjacent meningeal cov-
ering and may compressnerve roots. Nerve root tumors are most
commonly associated with the cervicaland thoracic cord segments.
Following myelography, an intradural-extramedullary sign is seen
when a tumor lies within the subarachnoid space. However, if
invasion of the dura or cord occurs,or if the tumor lies outside of
the dura, a "classic"intradural-extramedullarylesion is absent.In
the latter instance,the tumor mass may causecompressionof the
cord. For paravertebralnerve root tumors, such as brachial plexus
tumors, CT or magneticresonanceimaging is necessaryfor identi-
fication.
 C a n i n ea n d Fel i neIntervertebral
D i scD i sease,Myel ography,
Figure 10-18, Latera and ventrodorsalprojectionsof the spineof a 1-year-old
co n tr a stm e d iu min stilla ti on.
a f t e r su b a r a ch n o id Therei s focaldi l ati onof the subarachnoi d
s p a c eo ve r T l2 a n d th e cr a n ia pl a r t o f T 1 3 . Thi s appearance
N o t eth e wid e n in go f th e co r d ln th e ve n tr o dorsal vi ew from cordcompressi on
llyis u su a ilyn o t p o sslb leto t e I i f arachnoi cysts
M y e l o g r a p h ica it
a r e t he r e su lto f p r io rsu r g e r yo r tr a u m a .
Arachnoid cysts
Benign, cyst-like areasin the subarachnoid spacemay causeextra-
medullary compression and neural signs. Histologically, these are
not true cysts becausethey are not lined with epithelial ce1ls.5'' tt
The cause of "arachnoid" cysts is unknown, but becausethey are
usually seenin young dogs, a congenital etiology is likely. Resistance
to CSF flow, possibly induced by trauma, resulting in backpressure
and dilation of the subarachnoidspace,has also been implicated
as a cause.With arachnoid cysts, survey radiographic examination
is usually normal. Following myelography, contrast medium fills
the "cystic" area, defining abrupt dilation of the subarachnoid
contrast medium column and compression of the adjacent spinal
cord (Fig. 10-18). It is important to recognize the intradural-
extramedullary location of arachnoid cysts so they can be differen-
tiated from nonsurgical intramedullary lesions such as hydromyelia
or syringomyelia. The intramedullary-extramedullary sign in this
instancediffers from that of a mass lesion (e.g.,neurofibroma) in
which a filling defect is present, as well as subarachnoid dilation.
Arachnoid cysts that arise from causesother than previous trauma
or surgery are commonly located in the dorsal aspectof the cervical
subarachnoidspace.t*' tt
References
1. Hoerlein BF: Canine Neurology: Diagnosis and Treatment, 3rd ed. Philadelphia,
\\rB Saunders,1978,pp 470 560.
2. DeLahunta A: Veterinary Neuroanatomy and Clinical Neurology, 2nd ed. Philadel-
phia, WB Saunders,1983,pp 186 188.
3. Trotter EJ: Canine intervertebral disc disease.In Kirk RW (ed): Current Veterinary
Therapy VI. Philadelphia, WB Saunders, 1977, pp 841-848.
.{. Kirberger RM, Roos CL Lubbe AM: The radiological diagnosis of thoracolumbar
disc diseasein the dachshund. Vet Radiol Ultrasound 33:255 26I, 1992.
5. Seim HB, Withrow SJ: Pathophysiology and diagnosis ofcaudal cervical spondylo-
myelopathy with emphasis on the Doberman pinscher. J Am Anim Hosp Assoc
I8:24I 251, 1982.
and S pi nalC ordDisease 125
Chihuahua
i s typi calof arachnoi dcysts.
by the cyst.
d are congeni talor i f they
6. -vVheelerSJ: Lumbosacral disease.Vet Clin North Am Small Anim Pract 22:859-
888. 1992.
7. Thatcher CT: Neuroanatomic and pathophysiologic aspectsof intervertebral disc
diseasein the dog. Probl Vet Med Intervert Disc Dis 1:337-357, 1989.
8. Evans HE, Christensen JC: Miller's Anatomy of the Dog, 2nd ed. Philadelphia,
WB Saunders,1979.
9. Toombs lT: Cen'ical intervertebral disc disease in dogs. Compend Contin Edu
PtactVet l4tl477 1488, 1992.
10. Shores A: Intervertebral disc slndrome in the dog. Part I. Pathophysiology and
management.Compend Contin Edu Pract Vet 7:639-647,1981.
11. Simson S: Intenertebral disc disease. Vet Clin North Am Small Anim Pract
22:889-897, 1992.
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
German shepherd dog. I Am Vet Med Assoc 19l:951-957, 1987.
13. Pardo AD, Morgan IP: Myelography in the cat: A comparison of cisternal versus
lumbar puncture, using metrizamide. Vet Radiol 29:89 95, 1988.
14. Shores A; Spinal trauma: Pathophysiology and management of traunatic spinal
injuries. Vet Clin North Am Small Anim Pract 22:859-888, 1992.
15. Prata R: Neurosurgical treatment of thoracolumbar discs: The rationale and value
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
("the ascendingslndrome"). I Small Anim Pract 13:425 437,1972.
17. Morgan JP, Miyabayashi T: Degenerative changes in the vertebral column ofthe
dog: A review of radiographic findings. Vet RadioI 29:72-77, 1988.
18. Felts JF, Prata RG: Cervical disc disease in the dog: Intraforaminal and lateral
extrusions. I Am Anim Hosp Assoc 19:755 760, 1983.
19. Widmer WR, Blevins WE: Veterinary myelography: A review of contrast media,
adverse effects and technique. J Am Anim Hosp Assoc 27:163 177,1991.
20. Olby Nl, Dyce l, Houlton IEF: Correlation of plain radiographic and lumbar
myelographic findings in thoracolumbar disc disease. J Small Anim Pract 35:345
350, 1994.
21. Roberts RE, SelcerBA: Myelography and epidurography. Vet Clin North Am Small
Anim Pract 23:307-329. 1993.
126 AXIALSKELETON
22. Burk RL: Problems in the radiographic interpretation ofintervertebral disc disease
in the dog. Probl Vet Med Interyert Disc Dis 1:381-481, 1989.
23. Sande R: Radiography, myelography, computed tomography and magnetic reso-
nance imaging ofthe spine. Vet Clin North Am Small Adm Pract 22:8I\-83\' 1992'
24. Wood AKW: Iohexol and iopamidol: New non-ionic contrast media for myelogra-
phy in dogs. Comp Contin Edu Pract Vet 10:32-36, 1988.
25. Widmer WR, Blevins WE, Cantwell HD, et al: Iohexol and iopamidol myelography
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 .
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
medim on the canine lumbar myelogram. Vet Radiol Ultrasound 35:430431' 1994'
28. Tilmant L, Ackerman N, Spencer CP: Mechanical aspects of subarachnoid space
puncture in the dog. vet Radiol 25:227-232, 1984.
29. Kirberger RM, Wrigley R: Myelography in the dog: A review of patients with
contrast medium in the central canal. Vet Radiol 3:253-258, 1993.
30. Wright JA, Jones DGC: Metrizamide myelography in sixty-eight dogs. J Small
Anim Pract 22:415 436,198I-
31. Adams WM: Myelography. Vet Clin North Am 12i295-3ll' 1971-
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.
33. Funquist B: Thoraco-lumbar myelography with water-soluble contrast medium in
dogs. I. Technique ofmyelography; Side effects and complications. J Small Arim Pract
3:53-66,1962.
34. Funquist B: Thoraco-lumbar myelography with water-soluble contrast medium in
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
3 : 6 7 7 3 ,1 9 6 2 .
35. Ticer J, Brown Sl: Water-soluble myelography in canine htenertebral disc protru-
sion. Vet Radiol 15:3-9, 1974-
36. Morgan JR Suter PF, Holliday TA: Myelography with water-soluble contrast me-
dium: Radiographic interpretation of disc herniation in dogs. Acta Radiol
3 I 9 (suppl) :2L7-23 0, 1972.
37. Matteucci ML, Ramirez O 3rd, Thrall DE: Radiographic diagnosis: Effect of right
vs. left lateral recumbency on myelographic apPearance of a lateralized erlradural
mass. Vet Radiol Ultrasound 40:351-352,1999'
38. Mattoon JS,Koblik PD: Quantitative survey radiographic evaluation ofthe lumbo-
sacral spine of normal dogs and dogs with degenerative lumbosacral stenosis' Vet
Radiol Ultrasound 34:194 206, 1993.
39. Lang I: Flexion-extension myelography canine caudal equina. Vet Radtol 29:242-
257, t988.
40. Selcer BA, Chambers JN, Schwensen K, Mahaffey MB: Epidurography as a diag-
nostic aid in canine lumbosacral compressivedisease:47 cases(1981-1986). Vet Comp
Orthop Tiauma 29:97-103, 1988.
41. Stickle RL, Hathcock JT: Interpretation of computed tomographic images. Vet
Clin North Am 214L7-435, 1993.
42. Feeney DA, Fletcher TF, Hardy RM: Atlas of Correlative Imaging Anatomy of the
Normal Dog. Philadelphia, WB Saunders, 1991.
43. Sharp NJ, Cofone M, Robertson ID, et al: Computed tomography in the evaluation
of caudal cenical spondylomyelopathy of the Doberman phscher. Vet Radiol 36:100-
108, 199s.
44. Iones JC, Wilson ME, Bartels JE: A review of high resolution computed tomogra-
phy and a proposed technique for regional examination of the lumbosacral spine. Vet
Radiol 35:339-346,1994.
45. Morrison WB: Cancer affecting the nervous system. In Morrison WB (ed): Cancer
in Dogs and Cats-Medical and Surgical Management. Philadelphia, Willims &
Wilkins, 1998, pp 6s5-666.
46. Luttgen PJ, Braund KG, Brawner WR, Vandevelde M: A retrospective study of
twenty-nine spinal tumours in the dog and cat. J Small Anim Ptact2l:2134'16' 1980'
47. Luttgen Pl: Neoplasms of the spinal cord. Vet Clin North Am Small Anim Pract
22:973-984, 1992.
48. Waters DJ, Hayden DW: Intramedullary spinal cord metastasis in the dog. I Vet
Intem Med 4:207 2f5.1990.
49. Dallman ML Saunders GK: Primary spinal cord lymphosarcoma in a dog. I Am
Vet Med Assoc 189:1348-1349,1986.
50. Oliver IE, Lorenz MD, Kornegay IN (eds): Handbook of Veterinary Neurology,
3rd ed. Philadelphia, WB Saunders, 1997, pp 162-163.
51. Kirberger RM, Jacobson LS, Davies lV, Engela l: Hydromyelia in the dog. Vet
Radiol Ultrasound J8:30-38, 1c97.
52. Cook lR lr: Fibrocartilaginous embolism. Vet Clin North Am Small Anim Pract
18;581- 592,1988.
53. Oliver JE, Lotenz MD, Kornegay IN (eds): Handbook of Veterinary Neurology,
3rd ed. Philadelphia, WB Saunders, 1997, p I22.
54. Cambridge AJ, Bagley RS, Britt LG, Silver GM: Radiographic diagnosis: Arachnoid
cyst in a dog. Vet Radiol Ultrasound 38:434-436, 1997.
55. Bendey JF, Simpson ST, Hathcock JT: Spinal arachnoid cyst in a dog. J Am Anim
Hosp Assoc 27:549-551, 1991-
m Ouestions
l. In non-chondrodystrophic breeds, intervertebral disc diseaseis
tlpified by
A. Chondroid degeneration.
B. Fibroid degeneration.
C. Severeneurologicsigns.
D. Disc prolapse atTl2-13 and T13-L1.
E. All of the above
F. None ofthe above
2. Which of the following is correct with respect to the canine
spinal cord?
A. The conus medullaris ends caudal to L6 in large-breeddogs.
B. In the lumbar region, the cord segmentslie caudal to the
corresponding vertebral segment.
C. The pia is the thinnest meningeal layer and covers the
spinal cord.
D. The ratio of spinal cord-to-vertebral canal is highest in the
cervical region.
E. None of the above
F. All of the above
3. Regarding the pathophysiology of intervertebral disc hernia-
tion, which of the following is correct?
A. The cord can better withstand slow deformation than ex-
plosive concussion.
B. Typ" I lesions tend to cause more acute injury than type
II lesions.
C. Tlpe II lesions are a result of fibroid degeneration.
D. Pathologic changesare causedby mechanical disruption of
the cord and by chemical and vascular alterations.
E. All of the above
F. None ofthe above
4. Name three technical considerations that engender good-qual-
ity radiographs of the vertebral column.
5. What are four suiley radiographic,signs of intervertebral disc
disease?
6. Which is true regarding disc mineralization?
A. Disc mineralization begins peripherally and extends cen-
trally.
B . Disc mineralization is a dystrophic change.
Disc mineralization and disc prolapse are synonymous,
D. Only the annulus fibrosus undergoes mineralization.
E, All of the above
F. None of the above
7. Which is true regarding myelographic technique?
A. Iodinated ionic contrast media like meglumine diatrizoate
are safe and efficacious for myelography.
B. Cervicai myelography is accomplished by puncture of the
ventral subarachnoid space.
C. Lumbar myelography can be most easily accomplished by
puncture ofthe dorsal subarachnoid spaceat L4-5 or L5-6.

Figurc 1O-19
D. The normal myelogram is characterized by uniform, thin
contrast columns and uniform cord width, except at the
cervicaland lumbar resions.
E. All of the above
F. None of the above
8. The myelogram shown in Figure 10-19 was obtained from a
7-year-oId, female, mixed-breed dog with neck pain. What
type of myelographic pattern is present?
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
obtained using portable x-ray machines and fast intensifying
screens, and many referral centers have equipment capable of
imaging the entire vertebral column. Lateral views of the cervical
and thoracic spine may be obtained with the patient standing in a
normal position, but if a iong exposure time is required because
of thick body parts, motion blurring often decreasesthe amount
of information obtained from the examination. Diagnostic lateral
r.iews of the thicker regions and virtually all ventrodorsal views of
The EquineVertebralColumn 127
9. What is the causeof the opacification iust dorsal to the dorsal
subarachnoid spacear L5-6 ofFigure l0-7C?
10. Type I disc lesions often causeintramedullary swelling as well
as an extramedullary pattern. Which type of myelographic
pattern is most typical of tlpe II disc herniation?
Answers begin on page 727.
the spine require general anesthesiaand higher output systems.If
available,computed tomography {CT) can be uery uieful ior evalu-
ation of the cranial cervical spine in adult horses, and of more
caudal segmentsin foals. The limitations of CT include the require-
ment of generai anesthesiaand the inability to position all spinal
segments into the imaging gantry. Personnel and patient safety,
radiographic quality, and the likelihood of findine a lesion should
always be weighed carefully before an examinati6n of a standing
or anesthetizedhorse is performed.
I28 AXIALSKELETON
I Positive-contrast
I myelography
Although limited to the cervical spine in adult horses, positive-
contrast myelography is still the most practical method of obtaining
an antemortem diagnosisof cervical vertebral instability-malforma-
tion syndrome,the most common causeof ataxia in horses.l'2
Myelography is a relatively safe procedure and may result in
more accurate identification of compressive spinal cord lesions
than can be attained with survey radiography.'-e The dynamic
aspectsof the vertebral column and its relationship to the spinal
cord are important to evaluate, and myelography should always
include multiple positional views.3'nEquivocal myelographic find-
ings should always be correlated with clinical and laboratory find-
ings before a final diagnosis is made. Cerebrospinal fluid analysis
should also be routinely performed on horses undergoing myelog-
raphy.
Cervical myelography is accomplished by injecting a nonionic,
iso-osmolar, water-soluble, iodinated contrast medium into the
subarachnoid spaceat the occipitoatlantal junction with the patient
under general anesthesia.Iopamidol and iohexol are commonly
used contrast media. Metrizamide, the first low-osmolar contrast
medium used in veterinary medicine, is associatedwith high mor-
bidity. Morbidity and mortality rates associatedwith equine mye-
lography have been reported to be 15% for metrizamide and 1%
for iopamidol.3
In another comparison of metrizamide and iohexol in horses,
there was a much lower incidence with iohexol of adversepostmy-
elographic reactions, including seizures, intensification of preex-
isting neurologic signs, and prolonged recovery; there was no
recognizeddifference in the diagnostic quality of the myelograms''o
On neutral lateral projections, the dorsal aspect of the contrast
medium column is slightty wider than the ventral aspect. The
ventral aspect normally narrows to a thin line at the dorsal aspect
ofeach intervertebraldisc spaceon flexion ofthe neck (Fig. ll-1).
During hlperextension of the neck, the contrast medium column
should appear similar to that in the neutral position'
Myelograms in the horse should be examined for narrowing of
the contrast medium column within the subarachnoid space,as for
other species.Most compressivelesions of the cervical spinal cord
in horses, howevet are d1'namic; the dorsal aspect of the contrast
medium column may be normal in the neutral position but nar-
rowed during flexion of the neck with cranial cervical lesions or
during extension with caudal cervical lesions.3
The major problem in equine myelography arises from the fact
Figufe 1I-1. A, Lateralmyelogramof the midcervicalarea in flexed position.Largearrows, Dorsalaspect of contrastmedium column. Smallarrow, Normal
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
(arrowheads), but the dorsalaspectis wide, makingthe clinicalsignificanceof the ventralnarrowingunlikely.
that the degree of subarachnoid space narrowing that indicates a
spinal cord lesion remains undetermined. A diametrically opposed
narrowing of the dorsal and ventral aspectsof the contrast medium
column of at least 50olo compared with the same location in
other positionshas been propo."d as significantcord compression.3
Others have suggestedthat narrowing of the dorsal aspect of the
contrast medium column to less than 2 mm confirms the diagno-
sis.rt These criteria, however, have never been validated in a con-
troiled study. Both false-positive and false-negativesites of cord
compression have been reported with equine cervical myelogra-
phy.tt't'
Becausethe width of the subarachnoid space may vary among
individuals, and becausenarrowing of the contrast medium column
is dependent on the degree of flexion or extension of the neck,
measurementsas well as subjective evaluation of the width of the
contrast medium column should be interpreted with caution.3
One should avoid excessiveflexion and exLnsion until a severe
compressive lesion is ruled out, to avoid further damage to the
spinal cord, but attempts should be made to get maximum flexion
or extension of a particular segment of the spine if an equivocal
lesion is found. Unfortunately, the degree of flexion and extension
necessaryto confirm a dynamic cord compression, as well as the
extent of variation in the width of the subarachnoid space in
normal horses, is unknown.3 All preparations for myelography
should be made and the equipment necessaryto obtain flexion and
extension views should be readily available as the subarachnoid
contrast medium will undergo rapid dilution and absorption,
thereby degrading the diagnostic quality of the myelogram within
30 to 45 minutes followins contrast medium administration.
I Gongenital anomalies
With the exceotion of cervical vertebral malformation, most con-
genital anomalies of the vertebral column have little or no clinical
significance. Prominent dorsal spinous processesof the cervical
vertebrae and cervical ribs, fusion of the dorsal spinous processes
of the thoracolumbar spine, block (fused) vertebrae, and hemiver-
tebrae may be clinically silent and often remain undetected. Block
vertebrae and fused vertebrae may occasionally be associatedwith
scoliosis,lordosis,or kyphosis.l3
Occipitoatlantoaxial malformation is an apparently inherited
syndrome, common in Arabian horses, that is characterized by
varying degreesof hlpoplasia and fusion of the occiput, atlas, and
axis.laSeveralvariations are reported, but usually hypoplasia of the
atlas occurs with fusion to the occiput, accompaniedby hypoplasia
becausethe dorsalas pec tof the
disc space at C5-6 (arrow)is thinnerthan the ventraland dorsalaspectsat other sites

Figure 11-2. A, Lateralradiographof the cranialcervicalsegment in a foal
with ataxiadue to atianto-axial
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
(arrow),and smallosseousfragmentscan be seen betweenthe ventralaspect
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
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-
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.
of the axis, which may resemble an atlasl5 (Fig. 11-2). Clinical
signs of cranial cervical compressive myelopathy may be recognized
shortly after birth, or later, as acute or progressive ataria and are
usually more pronounced than are clinical signs in most horses
with cervical vertebral malformation s)'ndrome.I6
I Infectious lesions
A common infectious lesion of the spine in horses is osteomyelitis
of the dorsal spinous processesof the cranial thoracic vertebrae as
an extension of infectious supraspinousbursitis (fistulous withers).
Often, the infection is limited to the supraspinous bursa and
surrounding soft tissues.It is often difficult to determine whether
osteomyelitis is present becausethe separateossification centers of
the dorsal spinous processesin the affected area are normally
irregular and mottled, which mimics bone inflammation. In addi-
tion, it is normal for there to be periostealbone proliferation at
the insertion of tendons and ligaments on the spinous processes.
Therefore, one should search carefully for lysis of the body of the
spinous process or for aggressiveperiosteal reaction to confirm a
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,
should be ruled out with appropriate tests.
The diarthrodial joints of the spine may become secondarily
involved during septicemia in foals, and vertebral osteomyelitis
The EquineVertebralColumn l2g
(spondylitis) may result from direct extension or hematogenous
spread of bacterial or fungal infections. If such conditions are
suggestedby the clinicai findings, one should look carefully for
osteolysis,bone proliferation, and swelling of the surrounding soft
tissues.Bone lysis rarely becomesvisible on radiographsbefore 10
days from the onset of an infectious process, and periosteal new
bone formation is apparent even later, after 4 or 5 more days.
Discospondylitis has also been reported in the horse, but its inci-
denceis unknown.rT
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
prior to radiographyunder generalanesthesia.20
In selectedregions,
ultrasound may be useful to confirm displaced fractures of the
vertebralspinous processes.
I Acquired lesions and lesions
I of unknown etiology
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-
phy for the detection of this condition are low Bone scintigraphy
provides a more sensitivemethod by which to evaluate the sacroil-
iac joints in horses,and it does not require generalanesthesia.r3
Thoracolumbar spondylosishas been observed in old horses,
with or without clinical signs of back pain.r3,22As in dogs and
people, the clinical significance of this finding is difficult to derer-
mine radiographically.
Overlappingof the dorsal spinous processesof the thoracolum-
bar segmenthas been suggestedas a causeofback pain, particularly
in jumpers.r3'" Radiographicsignsinclude narrowing of the inter-
spinousspacewith remodelingof adjacentdorsal spinousprocesses
and pseudoarthrosis.Fusion of adjacent dorsal spinous processes
is rare.r3 Although these radiographic signs are easily identified,
their clinical significance is difficult to determine because they
are also seen in clinically normal horses.r3, ,, Soft-tissueinjury is
undoubtedly the most common cause of back pain in the horse,r,
and there may be a tendency to place too much significance on
radiographically visible osseouschanges.As in most instances,the
significance of any radiographic findings should be determined
clinically.
I Ataxia
The differential diagnosis of ataxia in horses is extensive and
includes compressiveand noncompressivemyelopathies.I', The
cervical vertebral malformation-instability syndrome (wobbler dis-
I3 0 A X I A LS K E L ET ON
Figure 11-3. Lateralradiographof the thoracicspinouspro-
c es s e so f a h o r s ew i t h fistu lo u swith e r s.T h e r eis a cu r vilin e a r
area of decreasedopacitysuperimposedover the spinouspro-
cess of T2 (smallarrowheads).This may be an area of bone
ly s rso r a s u p e r i m p o s i tioonf a fistu lo u str a ct in th e so ft tissu e s.
T he c a u d aal s p e c to f t h e sp in o u sp r o ce sso f T 4 is ch a r a cte r ized
by the normal irregularmargin (largearrowhead)at the attach-
ment of epaxialmuscuaturetendons.lnset, LeIt lateralee-tech-
net i u mm e t h v l e n ed i p h o sp h a te ( ' g e m T c- M DP)
b o n e scin tig r a mo f
t he s a m e a r e a .T h e a r e a o f in cr e a se dr a d io p h a r m a ce u tica
take (solid arrow) indicates involvement of a spinous process
(determinedas T2 usrnga radioactivemarker[openarrow]during
t he s t u d y ) .T h e s p i n o u sp r o ce sso f T 1 a L soa p p e a r sto h a ve
in cr e a se dr )a d io p h a r m a ce u tica
s ligh t l yl e s si b u t s i g n i f i ca n tly
t ak e .S C ,s c a p u l aS; P ,c r a n iath l o r a cicsp in e .
ease)is the most common causeof equineataxia,rand antemortem
confirmation of the diagnosis is based on radiographic examina-
tion.r e'tt Survey radiographicvertebrai measurementindices have
been proposed as sensitiveindicators by which to screenfor cervical
vertebral malformation s)'ndrome.24Semiquantitative radiographic
indicators were reported to be an accurate method of diagnosing
and predicting cervical vertebral malformation in Thoroughbred
foals up to 1 year of age.2sDefinitive antemortem diagnosisrequires
myelography to accuratelyidenti$u the actual sitesofcord compres-
1 1 ,2 6 ,2 7
s i o n .3 ,4 ,
Cranial cervical and caudal cervical radiographs in neutral and
flexed positions should be included in both survey and myelo-
graphic examinations. Myelographic examination should also in-
clude a caudal cervical view in extended position because most
dorsal compressivelesionsare seenat C6-C7 and C7-T1.'
Survey ridiographs are examined for the following changes:(1)
remodeling of the caudal aspect of the floor of the vertebral
canal, (2) proliferative responseat the articular processes,and (3)
apparent narrowing of the vertebral canal in neutral, flexed, or
extendedposition3(Figs. ll-5 and 11-6). Significantbone remod-
eling of the vertebrae may occur without myelographic evidence of
spinal cord compression,and soft-tissue lesions, including synovial
cysts and hypertrophy of the dorsal longitudinal ligament, may
cause spinal cord compression with no abnormalities visible on
survey radiographs.' Therefore, myelography is warranted to con-
',to t
u p l-
u p -l
firm spinal cord compression.3'12'18If available, contrast-enhanced
CT yields the most sensitiveevaluation and qualitative information
regarding the source,severity,and location of spinal cord compres-
sion.lr
In a study including 309 ataxic horses, 587o had myelographic
evidence of a compressivespinai cord lesion.3 In decreasingorder
of frequency, the most common sites of compression were C3-C4,
C6-C7, C5-C6, and C4-C5, tn 32o/o,77o/o,74o/o,and 11oloof a1l
horses, respectively.Two compressivelesions were seen in 17o/oof
these 309 ataxic horses, and lo/o had evidence of spinal cord
compression at threesites.
The mechanisms leading to the myelopathy in cervical vertebral
malformation-instability syndrome are not fully understood. In
many patients, repetitive trauma to the spinal cord appears to be
causedby positional narrowing of the vertebral canal, which sup-
ports the premise that evaluation of dynamic changesis extremely
important in myelography. Stretching of the spinal cord against
remodeled bone may also be incriminated in the pathogenesis
of the myelopathy, and absence of myelographic signs of cord
compression may not preclude a diagnosis of cervical vertebral
malformation-instability syndrome.tt,L Although intervertebral
disc herniation has been reported in horses,the condition is rare
and other causesof extradural compression should be considered.
Extradural lateral compressivelesions are exceedinglyrare.3They
should cause widening of the spinal cord as well as narrowing of
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.

Figure 11-6. A, Lateralradiographof the caudalcervicalarea of an ataxic2-year-oldHanoverianstalljon.There is periartcularbone prolrferation

at the ar.cutar
processesar C6-l (openarrow).B, Lateralmyelogramof the same aTeaduringextensionof the neck. Both the ventraland dorsalaspects
of the contrastmedtum
columnare narrowedaIC6-7 (smallarrowsr.The width of the columnwas normalon other views, whtch is typicalof a caudalcervlcallesion.
132 AXIALSKELETOII

the contrast medium column on the lateral view. They are difficult
to confirm with ventrodorsal views becauseof numerous superim-
oositions and increased scattered radiation' both of which reduce
iadiographic detail.'?8Contrast-enhanced CT has proved useful for
docuirenting lateral compressivelesions of the spinal cord caused
by malformed articular processes.rr
A large proportion of ataxic horses do not have radiographic
signs oiceiviial vertebral malformation-instability syndrome;
th-erefore,the numerous other causesof cervical spinal cord dis-
eases should always be considered in the differential diagnosis'
Equine protozoal myeloencephalitis and herpes virus type 1 mye-
loencephalitis may have clinical signs that partially,mimic cervical
vertebial malformation but lack radiographic and myelographic
abnormalities. In such patients, analysisofserum and cerebrospinal
fluid provides information about exposure to Sarcocystisneurona
24. Moore BR, Reed SM, Biller DS, et al: Assessmentof vertebral canal diameter and
bony malformations of the cervical part of the spine in horses with cewical myelopa-
thy. Am I Vet Res 55:5, 1994.
25. Mayhew I, Donawick W, Green S, et al: Diagnosis and prediction of cervical
vertebral malformation in Thoroughbred foals based on semi-quantitative radio-
graphic indicators. Equine Vet J 25:435, 1993.
26. Neuwirth L: Equine myeolography. Comp Contin Educ Pract Vet 14i72, 1992.
27. Moore BR, Granstom DE, Reed SM; Diagnosis of equine protozoal myelitis and
ceryical stenotic myelopathy. Comp Contin Educ Pract Yet 17:419, 1995.
28. Foss RR, Genetzky RM, RiedeselEA, et al: Cervical intervertebral disc protrusion
in two horses.Can Vet I 24:188,1983.
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.
30. Wilson WD: Equine herpesvirus 1 myeloencephalopathy.In Reed SM, Bayly WM
(eds): Equine Internal Medicine. Philadelphia, WB Saunders, 1998.

and the herpesvirus.2e'30

References ffi Ouestions

L Reed SM, Bayly WM, Traub JL, et al; Atuia and paresis in horses; I' Differential
diagnosis. Comp Contin Educ Pract Vet 3:88, 1981.
2. Mayhew IG, Whitlock RH, delahunta A: Spinal cord diseasein the horse Cornell
Vet Suppl 6:13,1978.
1. Of metrizamide or iopamidol, which nonionic iso-osmolar,
water-soluble iodinated contrast agent has the higher incidence
of adversereactions in equine myelography?

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.

19. Ricadi G, Dyson SI: Forelimb lamenessassociatedwith radiographic abnormalities

of the cervical vertebrae. Equine Vet J 25:422' 1993-

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.

6. In ataxic horses with compressivelesions on myelography, the

*0.' l
most commonly reported sites in order of frequency were: u,
A. C3-C4, C6-C7, C5-C6, and C4-C5. -t
B. C4-C5, C6-C7, C5-C6, andC3-C4.
C. C3-C4,C4-C5, C5-C6, andC6-C7.

7. The incidence of two compressivelesions and the incidence of

three compressivelesions in the same horse were reported to "' ""''l
be what percentages,respectively?
;-.."- "--
." ".t',-""i
A. 50o/oand 25o/o
B. 33o/oand 10olo
C. L70/oand 7o/o
D. 5o/oand 0.5o/o

8. Which of the following infectious diseases can mimic the

clinical signs of cervical vertebral malformation in horses?
A. Equineinfectiousanemia
Figure I 1-8
B. Equine protozoal myeloencephalitis
C. Equine strangies
D. Lyme disease
10. A 3-year-oid Thoroughbred with ataxia was examined with
9. A 2-year-old Thoroughbred horse with signs of ataxia was survey and contrast myelography. What is your assessmentof
examined. Survey radiographs of the cervical spine were nor- the portion of the contrast myelogram shown (Fig. ll-g).
mal. A contrast myelogram was performed. What is your Which vertebra is designatedby the arrow?
assessmentof the myelogram (Fig. 11-7), in which C2 through
a < ..^ A ^ ^;-+-42
Answers begin on page 727.

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
Radiographic evaluation of the small animal appendicular skeleton
is based on the basic four-step process (detection, description,
differentialfor abnormal or deviation from normal, and diagnosis)
outlined in Chapter 5. The purpose of this chapter is to provide
an overview and a framework to build on relative to the other
chaptersin dealing with evaluation of small animal musculoskeletal
radiographs. Some information will be redundant but it is critical
to understandthesebasic concepts.The reader should be able to
apply the basic interpretation paradigm or models presentedin this
chapter to any radiographic study of the small animal appendicular
skeleton. A basic concept is the fact that bone is continuously
remodeling throughout the animal's life, and under normal cir-
cumstances(appropriatestressesand biomechanics),bone remod-
eling provides a balancebetweenproduction and resorption.t''?
I Bone formation
From an embryologic standpoint, all bone is derived from meso-
derm.t Initial bone formation is derived from precursor mesenchy-
mal cells that align themselveswith each other. This results in cell-
to-cell contact and local humoral interaction, Ieading to cellular
differentiation. The osteoprogenitor cells are pluripotential mesen-
chymal cells that have the capacity to differentiate into osteoblasts,
chondroblasts,fibroblasts,and other hematopoieticprogenitor
cells; these in turn give rise to monocytes, macrophages, and
osteociasts.ra
The osteoblast is the primary precursor cell responsible for
bone development and the synthesis of osteoid, the proteinaceous
organic matrix of the skeletal system. Synthesizedproteins include
type I collagen, which accounts for 90o/oof the organic component
of the normal bone matrix. As bone matures,the organic osteoid
matrix becomes mineralized. The blend of osteoid (35olo)and
inorganic matrix (65%) accounts for the basis of normal bone
strengthand hardness.The inorganic matrix is made up of calcium
hydroryapatite [Ca'o(PO")u(OH),],and the specific details of its
formation are not well understood. The rate of mineralization can
vary, but there is normally a 12- Io 15-day lag time between osteoid
formation and mineralization of the matrix. As the immobile
I 'iiiirrrll:
1!$lll
,':- t" - . r* " ' -, 1...:iiiii€llll'''riii,
t1 t 111::::,.,rrt.,],,,
: : , : 1. : , . . : . . 1: ," -
--"".
t
--- " .,
,'*;
ll9l,,.lll
liilUll'
osteoblast lays down osteoid, its capability for further osteoid
formation decreases;at this point, the cell is called an osteocyte.
Osteocytesare the most plentiful cells found in mature bone, and
they are interconnected by a complex system of tunnels called
canaliculi.t-
Osteoclastsare multinucleated (n : 6 to 12 nuclei) cells formed
from circulating mononuclear precursors.r',Typically, osteoclasts
align along a shelf of bone. As the osteoclaststarts the resorption
process,it forms a resorption pit and secreteslysosomal enzyrnes
and hydrogen ions into a secondary lysosome along the bone
surface. This initiates the breakdown of the inorganic and organic
matrices of bone. Byproducts of this breakdown process, such as
calcium and phosphorus, can be absorbedby the osteoclastand
then releasedon the other side of the cell, thereby contributing to
the maintenance and balance of these minerals throughout the
body. Osteoblastsand osteoclastsact in coordination and are con-
sidered a functional unit known as the basic multicellular unit.
During skeletalgrowth and maturation, bone production predomi-
nates,but as the animal matures and bone growth ceases,a balance
resultswherebybone production equalsbone resorption.a,s
Bone is formed through a processof mesenchymalmodels.',n
One model is endochondral ossification, in which mesenchymal
progenitor cells first differentiate into a cartilaginous model that
forms the framework from which bone is formed. Durine endo-
chondral ossification, cartilage cells (chondrocytes) matureihyper-
trophy, undergo mineralization within the matrix secretedby the
chondrocytes, and ultimately die. This area of cell death forms
the scaffolding for ingrowth of blood vessels(angiogenesis) and
osteoprogenitor cells that differentiate into osteoblasts.In a long
bone, the model of endochondral ossification is located in the
physis and metaphysis, and this is where active bone formation
takes place. The metaphysis is also called the primary center of
ossification.
In a tlpical long bone, the shaft is called the diaphysis. Pro-
gressingaway from the diaphysis is the metaphysis,the physis, and
then the epiphysis (Fig. 12-l). The physis is the cartilaginous
model that leads to the development of metaphysealbone. Within
each epiphysis, a secondary center of ossification develops from a
cartilaginous model. As this secondary center of ossification devel-
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

Other physes,such as the proximal tibial physis, close unevenly, as

is discussedlater.
The distal ulnar physis has a conical shape, with the point
extending distally into the epiphysis. There is also a transverse
radiolucent line across the ulnar metaphysis corresponding to the
flared rim of the physis that is parallel to the primary x-ray beam
(Fig. I2-2). Becauseof the unique anatomic arrangement of the
distal ulnar physis, it is particuiarly susceptible to compaction
injuries and premature closure.
An apophysis is a secondary center of ossification in areas of
ligamentous or tendinous attachment to bone. Examples include
the greatertubercle of the proximal humerus, the greatertrochanter
of the proximal femur, and the anconeal process of the proximal
ulna. Occasionally, the apophysis and the parent bone may not
fuse. For example, the anconeal process is expected to fuse with
the ulna by 6 months of age at the latest. Thus, the diagnosis of
an ununited anconeal processwould be made if a radiolucent line
is present between the anconeal process and the olecranon at 7
months of age. In certain instances,the failure of ossification does
not imply pathology and should not be mistaken for a fracture. A
working knowledge of the physeal closure times and patterns is
paramount for evaluating radiographs ofthe appendicular skeleton
in dogs and cats. When in doubt, remember to radiograph the
other limb, as physes are bilaterally symmetrical. Physeal closure
times are also impacted by various hormones such as somatotropin
(growth hormone), th1'roxine,and triiodothyronine. Failure of nor-
mal hormonal interaction with the chondrocl.tes of the physis
results in abnormal development and delayed closure.3
Osteoprogenitor cells are also present in the inner cambium
layers of the periosteum and endosteum. These cells, which allow
for growth and remodeling of the cortex of the bone, remain active
Figure 1z-1. Mediolateral radiographof the antebrachium of a dog The
andulnarlongbonesis the dlaphysis
of the radial
mid-shaft /D. Thesection
whereactiveboneremodeling is takingplaceis the metaphysis (M) fhe
zoneis the endochondral
radiolucent ossificationcentercalledthe physis1Pl
Thepartof the boneclosestto thejointis calledthe epiphysislEl Theendof
theepiphysisis coveredby hyaline
cartilage withthe nextbone
andarticulates
joint.
at thesynovial

metaphysis. The physis and metaphysis contribute to increased

length and width of the bone toward the diaphysis; the epiphysis
contributes to increasedlength and width of the end of the bone.
Osteoprogenitor cells in the epiphysis form the subchondral bone,
articular cartllage, and surface for articulation with the adjacent
bone. These areasof active bone remodeling and new bone forma-
tion, particularly the metaphysis, are the predominant sites of
origin for primary bone tumors. The physis is important from a
radiographic standpoint in that it is radiolucent relative to the
mineralized osteoid of the epiphysis and metaphysis.GeThe physis
is also susceptible to injury and is a weak link when long bones
are traumatized.
a
Histologically, there are four zones in the physis.'z' Beginning at
the epiphysealside, they include (1) the reserve zone, (2) the zone
of proliferation, (3) the zone of hypertrophy, and (4) the zone of
mineralization. Fractures through the physis typically occur in the
€rr!S
zone of hlpertrophy. If a physeal fracture is suspected but not :rrrata
identified, the patient should be re-radiographed every 7 days for
.liilill::.rrrl
the next several weeks to ensure that the physis has not been !:\:::!,::::,
1119t:iill
damagedand that bone is elongating normally. As the physis closes, lr;rglll,,,
the radiolucent gap between the metaphysis and the epiphysis t ,,119,,.,,,

narrows and becomesnonexistent. Initially, a radiopaque line called

the physeal scar develops.As the animal ages,this area undergoes
remodeling, and the physeal scar disappearsmaking the cancellous,
intramedullary area of the epiphysis continuous with the metaphy-
sis. On the average,the physis of long bones closes at between 8
and 14 months of age. Large dogs tend to have longer physeal
closure times than small dogs. Some physes, such as the physis
associatedwith the wing of the ilium, may remain open indefinitely'
Figure l2-2. Close-upmediolateralradiographof the distal ulnar physis.
N otethe uni queappearance e prema-
of the physi s.Thi sphysi si s suscept i blto
ture closuresecondaryto compactioninjuries.Thereis a step malallgnmento{
the distal radialphysis.This is secondaryto a type ll Salterfracture of the
distalradialDhvsis.
 l n terpretati on
P aradi gms
for the A ppendi cul ar
S kel eton-cani neand Feline lg7

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

featur'es that are considered benign in character (see later). In

an aggressivelesion, specific bone responses indicate an active'
ongoing process.
The distinction between nonaggressiveand aggressivelesions is
important becauseof the potentially life-threatening consequences
of their underlying causes(e.g., neoplasia and infection). When an
aggressivebone lesion is identified, the next step is to obtain
thoracic radiographs and open biopsy with histopathologic and
microbiologic evaluations of the sample.
Parametersto be evaluated in distinguishing a benign from an
aggressivelesion are:
. Presenceof bone disruption, particularly involving a cortex
. Pattern of bone lysis
' Type of periosteal reaction
. Characteristicsof the zone of transitiont'' t3

Patterns of bone destruction should be categorizedusing the

following criteria:
. Localized or generalizeddemineralization
. Presenceand degree of cortical destruction
. Presenceof intramedullarv lysis
. Pattern of lysis
-Geographic
-Moth-eaten
-Permeative
It is also important to characterizethe lesion location within the
bone as epiphyseal,physeal,metaphyseal,or diaphyseal.
With regard to patterns, focal geographic areas of lysis tend to
have well-defined margins and are the least aggressiveform oflysis.
Geographic lysis might be caused by a lesion such as a bone cyst
(Fig. 12-a) or a bone abscess.With geographic lysis, the cortex
may be expanded but it usually has not been destroyed (is not
\tic). With moth-eaten lysis, there are multiple discrete areas of
lysis of variable size; the cortex may or may not be l1'tic. Moth-
eaten lysis is typically seen with bone tumor and infection (Fig.
12-5). The most aggressivepattern of bone lysis is permeative lysis
whereby focal areasof ill-defined osteolysisare Present throughout
1".---,
Figure 124. Geographicosteolysisin the femoralhead and neck of a dog
due to a bone cyst.
Figure 12-5. Permeative in a dogwith a primarybonetumorof
osteolysis
the proximal
humerus witha transversepaihologic
fracture.
Amorphous new
boneformationis notedsurrounding
the cranial
andcaudal aspects of this
bonetumor.Thehistologic
diagnosis
wasosreosarcoma.
a region of bone (Fig. 12-6). Moth-eaten and permeative lysis are
indicative of an aggressivelesion.t-tu It is important to remember
that lysis represents a continuum of change, and several patterns
of lysis may be present in the same bone. The most aggressive
pattern identified should be used to characterizethe lesion. One
can take the approach of waiting and making follow-up radio-
graphs. However, if an aggressivecomponent is present, radio-
graphic reevaluation should take place within 4 to 10 days, as
aggressiveiesions change quickly.
Production of new bone is also a commonly encountered re-
sponse to bone disease.Bone production is either adjacent to a
joint or away from the joint. Bone production adjacent to a joint
is discussedlater.
Bone production away from the joint is either periosteal or
endostealproliferation and is usually located along the metaphyseal
and diaphyseal regions of the bone. As with osteolysis,there are
different types ofperiosteal reaction. Thesereactions are dependent
on local factors that stimulate new bone formation and the degree
to which the periosteal or endosteal iayers of osteoprogenitor cells
respond to the stimulus. The characteristicsof periosteal and end-
osteal new bone formation form a continuum, as was noted for
osteolytic lesions. The different tlpes of periosteal reactions, listed
in order of increasingaggressiveness, are:
. Smooth, solid new bone formation
. Multilayered or lamellar bone formation
. Spiculated bone formation
. Sunburst bone formation
. Amorphous new bone.
Smooth new bone formation is tlpical of focal trauma whereby
a subperiosteal hematoma or part of the periosteum has been
elevated away from the cortex. Smooth new bone production is
bone lesions(Fig. 12-7).
not a sign of aggressive
 In terpretati on
P aradi gms
for the A ppendi cul ar
S kel eton-C ani ne
and Feline 139

Figure 12-6. Moth-eatenosteoysis in a dog with metastaticneoplasiaof
the humerus.
Figure 12-7. Smooth periostealnew bone formationalongthe caudalcor-
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.

Multiple layers of new bone formation along a cortex can have

the appearanceof a multilayered onion skin and can be seen in a
variety of conditions ranging from focai trauma to infection to
neoplasia. A thick lamellar periosteal reaction that appears sepa-
rated from the cortex can be seen in the metaphysis of the distal
radius and ulna in immature dogs with hypertrophic osteodystro-
phy" (Fig. l2-8). As with smooth periosteal reactions,lameilar
periosteal reactions are usually associatedwith less aggressivedis-
eases,although occasionallybone tumors result in a lamellar peri-
ostealreaction.
A columnar (palisading)periostealreaction is new bone forma-
tion radiating perpendicularly from the long bone cortex as is seen
typically along the diaphysis of long bones with hypertrophic
osteopathy(Fig. l2-9), and occasionallyin bacterialosteomyelitis.
A spiculated pattern represents new bone formation in which
long rays of new bone radiate from a central, aggressiveosteolytic
or osteoproductive lesion, such as a primary bone tumor.
Amorphous new bone formation occurswhen new bone is being
laid down within soft tissues surrounding the bone, but the new
bone is haphazard and does not have a functional or organized
shapeor morphology (Fig. 12-10).|'z, 13
Another term used to describe periosteal new bone formation is
Codman's triangle. Here, the periosteum is elevatedfrom the cortex
(Fig. 12-11), and a triangle of smooth new bone is laid down.
Codman's triangle is a nonspecific periosteal reaction and can
occur with benign and aggressive processes.lt
One should also evaluate for intramedullary and endostealbone
production; however, this may be difficult owing to superimposed
cortical bone. Focal areasof bone sclerosiswithin the medullary
cavity are a typical manifestation of canine panosteitis, but may
alsobe due to bone metastasis.
When evaluating the spectrum of periosteal reactions and oste- Figure 12-8. Periostealcuffing and a smooth periosteaireaction in the
olysis, remember that the most aggressivepart of the lesion should regionof the metaphysisin a young dog with hypertrophicosteodystrophy.
I4 O S KE L ET ON -C A N INAN
A P P E NDI C U L AR E D FE LIN E

Figure 12-11. Periostealelevationfrom any cause can result in smooth,

new boneformati on.Thi s tri angl eof new bone formati oni s c al l edC odman' s
tri angl e,as seen i n thi s di stal humerall esi on.In thi s dog , the peri os teal
Figure 12-9. Columnarperiostealreactionof long bones. In this example, el evati onw as secondaryto an expansi l eosteosarcoma from the
ori g i nati ng
t his d o g h a d a p r i m a r ylu n g tu m o r a n d th e co lu m n a rp e r io ste al
reacti onw as di stalhumeralmetaphysi s. Therei s al soa pathol ogifracture
c w i th
as s oc i ated
l r te xo f m u ltip lelo n g b o n e s,wh ich i s consi stent
s ee n a l o n gt h e d i a p h yse aco the di stalhumeralmetaphvsi s.
with hypertrophicosteopathy.

define the lesion as to whether it has an aggressiveor benign

Figure 12-1O. Amorphous new bone formation within the soft tissues
adlacentto an osteolytic lesion of the proximal humeral metaphysis.This
new bone is secondaryto a primarybone tuTnor.
haphazard-appearing
character.A benign bone lesion would be one in which the perios-
teal reaction is smooth and solid in appearance.The lesion may be
somewhat expansile, but there is no cortex destruction, nor is
there radiographic evidence of permeative or moth-eaten lysis. An
aggressivelesion is one with aggressiveosteol).tic and osteoprolifer-
ative radiographic features. Once a lesion has been defined as
aggressive,one should always consider thoracic radiographs and a
biopsy of the lesion. Ultrasound-guided or blind aspiratesmay
provide cytopathologic results consistent with a sarcoma.ls
A fina1 characteristic that may help in assessmentof the aggres-
sivenessof a lesion is the appearanceof the region of transition
between the lesion and adjacent normal bone. With benign lesions,
or lesions that are not particularly aggressive,there is relatively
abrupt demarcation of the edge of the lesion. The edge of the
diseaseprocess in the bone can be delineated from adjacent unaf-
fected bone fairly precisely. This is called a "distinct transition
zone." With aggressiveiesions,the growth or extension of the lesion
into the bone makes identification of the edge of the lesion very
imprecise, and it is impossible to tell the limits of the lesion in the
bone. This is cailed an "indistinct transition zone."
In summarx the characteristicsthat should be assessedfor de-
termining whether a bone lesion is aggressiveinciude:
. Lesion location
. Pattern and degreeof bone lysis
. Presenceor absenceof cortical disruption
. Type of periostealreaction
. Characteristicsof the zone of transition
. Rate of change if follow-up radiographs are obtained.
All of these patterns fall along a continuum and need to be
considered when deciding whether a lesion is aggressive(Fig. 12-
 l n te rpretati on
P aradi gms
for the A ppendi cul ar
iz). If one is still undecided,it would be a good idea to obtain
thoracic radiographsat this stageand to re-radiographthe lesion
in 10 to 14 days.If the lesion has changed,the aggressive character
of the lesion may be more obvious.
Aside from whether a lesion is aggressive, lesion location and
the number of bones involved become important in establishing
the differential diagnoses.Whether a bone diseaseis monostotic
(one bone) or polyostotic (multiple bones) drasticallyinfluences
the rule-outs. For exampie, a monostotic metaphysealaggressive
long bone lesion should be considereda primary bone tumor
until proven otherwise.But, a primary bone tumor would not be
considered for multiple metaphysealaggressivelesions; infection or
metastatic neoplasia is more likely. Specific diseaseentities occur
within specificlocations; it is incumbent on the student or prac-
titioner to memorize these specific sites as key areasto be evaluated
on radiographsof a given joint. Thesediseasesare summarizedin
Table 12-1. Other sitesofspecific concernare reviewedin Chapters
13 (Diseases of the Immature Skeleton)and 16 (RadiographicSigns
of Toint Disease).
I Evaluating radiographs of a
I specific ioint
Radiographic evaluation of a joint in small animals consistsof two
orthogonal radiographs,usually a mediolateraland a craniocaudal
or dorsopalmar (plantar) view. Becausejoint radiographsin small
animals are usually obtained in a non-weight-bearing patient,
joint spacewidth is basically impossible to evaluate unless overtly
subluxated, luxated, or collapsed.
The synovial joint is made up of the hyaline cartilage covering
the epiphysealsubchondralbone, the joint capsule,and the syno-
vial fluid that bathes the cartilage with nutrients and oxygen.
Normal hyaline cartilage is a well-organized layer of chondrocytes
with surrounding tlpe II collagen fibers that form a meshwork for
proteoglycans,mucopolysaccharides,and water.+6
The responseof the joint and surrounding structuresto damage
is complex, and this process is oversimplified in the following
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 -
Nonaggressive
1. Location
Geographic
2. Bone destruction
3. Corticaldisruption None
4. Edge character or Sharp,distinct,or--->
zone of transition shortzone of transition
Smooth,continuous
5. Periosteal reaction
6. Rate of change None
(4 to 10 days)
F i g u r e 1 2 - 1 2 , C o n tin u u mo f r a d io g r a pchfe a tu r e so f b e n ignversusaggressi ve
d i s e a s eo, n e s h o u l dalwa yse va lu a tefo r th e p r e se n ceo f th e most aggressi vebone l esi on.
S kel eton-C ani ne
and Feline l4l
teoarthrosis are terms used to summarize radiographic changes
involving a joint but are generic with regard to etiology. Primary
degenerativejoint diseaseis a condition whereby no inciting factor
can be establishedand the etiology is not determined.This is seen
as an age-relatedchangein the shoulderjoints of dogs. Secondary
degenerativejoint diseaseis a condition whereby an inciting etiol-
ogy is present, such as an osteochondrosislesion or a previous
articular fracture.
The radiographic changesaccompanying degenerativejoint dis-
easecan be characterizedby the soft-tissueand bone responsesto
the degenerativeprocess.First, owing either to a biochemical or a
biomechanical abnormality the hyaline cartilage is damaged and
joint instabiiity develops. Inflammation and synovitis result in
periarticular soft-tissue swelling or intra-articular effusion, which
may be seenradiographically.The joint attempts to stabilizeitself
by thickening the supporting ligaments and through synovial hy-
perplasia.Radiographically,bone changesare the most commonly
identified changesnoted in associationwith degenerativejoint
disease.These changesinclude osteophlte formation, enthesophyte
formation, and subchondralbone thickening (Fig. 12-13). Osteo-
phytes occur along periarticular margins and are regions of new
bone formation that develop through a processof subchondral
bone marrow vascularizationat nonpressurepoints of a joint.
Enthesopathyis periostealnew bone formation from traction at
osseousattachmentsof joint capsule,ligaments,and tendons.Sub-
chondral bone sclerosis occurs when the normally thick hyaline
cartilageno longer actsas a buttressand cannot cushion the impact
of opposing bones. Progressivethinning of the hyaline cartilage
results in increasedstressto subchondral bone. As subchondral
bone mass increases,there is a correspondingincreasein radio-
graphic opacity. In advanced osteoarthritis, narrowing of the joint
space consistent with loss of normal hyaline cartilage can be seen
radiographically.Osteophytosis,enthesophytosis, and subchondral
sclerosisimply chronicity.
Over time, the remodeling associatedwith the degenerative
changesbecomes advanced.If articular cartilage becomes frag-
mented in the joint and embedded in synovium, it can undergo
endochondralossificationand appearradiographicallyas a miner-
Aggressive
Metaphyseal-primarybone tumor
Diaphyseal-metastasis
Moth-eaten Permeative
Yes-cortex is brokenor not seen.
+ A pathologicfracture
Indistinct,permeative,or
longzoneof transition
Interrupted,
variable,spiculated,
amorphous
Markedchanges
bonedi sease.When determi ni ng
the presenceor absenceo f aggres s i v bone
e
I4 2 R EL E T O N -C A N INAEN D FE LIN E
A P P E NDI CU L ASK

Table 12-1, Gommon causes of ioint disease of small animals

Joint Disease SPecies Site
S hould er Osteochondrosis D Caudalhumeral head (best evaluatedon medial
lateralradiograph)
Bicipitaltenosynovitis na Bicipitaltendon sheathand intertubercular
groove (arthrogrammay be helpfulfor
evaluation)
Trauma D ,C Any site
Congenitalluxation D ,C A b n o r m a l d e v e l o p m e n to f h u m e r a l h ea d a n d
glenoid cavity
Pr im ar yDJ D D ldiopathic-osteophyteformation at periarticular
locations,such as glenoid cavity and humeral
head
Synovialcell sarcoma D ,C Osteolysisalong joint capsuleinsertionsites
E lbow Felineprogressivepolyarthritis Osteoproliferative DJD of both elbows
Ununitedanconealprocess D Anconealprocessfails to fuse with olecranonby
6 months of age
Osteochondrosisof medial aspectof D On cranialcaudal radiograph,radiolucentdefect
distal humeral condyle in medial aspectof distal humeral condyle
Fragmentedmedial coronoid D Blunting,fragment, or absenceof medial
process coronoid orocess
Prematureclosure of distal radial or D.C DJD and subluxationof the elbow joint
ulnar phy s is
Synovialcell sarcoma D,C Osteolysisalong joint capsuleinsertionsites
Septic arthritis D (young) Osteolysisand remodelingof bones of elbow
joint
C a rpus Repetitivetrauma D,C OsteoproliferativeDJD; enthesopathyof the
accessorycarpal bone
Rheumatoidarthritis,SLE D >>C Resorptionof bone at areasof pannusformation
and synovial proliferation
Synovialcell sarcoma D,C Osteolysisalong joint capsuleinsertionsites
Pr'ematureclosureof distal radial or D,C DJD of the carpal and elbow joint(s)
ulnar phy s is
Coxofemoralioint Hip dy s plas ia D,C Subluxation,luxation,and DJD of coxofemoral
joint
Bilateralslipped capital physeal Widened capital physis or step malalignment
fractures with apple-coreappearanceof the femoral
neck over time
Trauma D,C Physealor femoral neckfracture
Aseptic necrosisof the femoral head D (small- Remodelingof head and neck.fragmentationof
breed dogs) femoral head;thickeningof femoral neck
Synovialcell sarcoma D Osteolysisalong joint capsuleinsertionsites
Osteochondrosis D Radiolucentdefect of femoral head
Stifle Ligamentousinstability D,C Joint effusion and DJD of femorooatellarand
femorotibialjoints
Patellarluxations D,C Joint effusion and DJD of femoropatellarand
femorotibialjoints
Osteochondrosis D Lateralfemoral condyle
Trauma D,C Any location
Synovialcell sarcoma D,C Osteolysisalong joint capsuleinsertionsites
Tarsus Osteochondrosis D Medial trochlearand lateraltrochlearridges
Trauma D,C Any location
Synovialcell sarcoma D.C Osteolysisalong joint capsuleinsertionsites
Rheumatoidarthritis,SLE D >>C Resorptionof bone at areasof pannusformation
and synovial proliferation

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

Figurc 12-13. Extendedleg ventrodorsalradiographfrom a

1 4 - m o n t h - o lL d a b r a d o r e tr ie ve rwith h ip d ysp la siaT. h e r e is
b i l a t e r aci o x o f e m o r allo in t su b lu xa tio a
n n d o ste o p h ytefo r m a-
t i o n a s s o c i a t ew d i t h th e fe m o r a h e a da n d n e cka n d th e d o r sal
a c e t a b u l arri m . T h e s ech a n g e sa r e se co n d a r toy th e in sta b il i ty
o f t h e c o x o f e m o r ai ol in t.

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

be written out. In private practice, this step is often skipped but it

forces one to evaluate the radiograph more critically. Then the
question that has to be answered is whether the abnormalities
identified are normal anatomic variants or true abnormalities.
When this is determined, a diagnosis or differential diagnosis
can be established.Pitfalls in interpretation of musculoskeletal
radiographsinclude:
. Poor technique
. Lack of systematicreview
. Not obtaining an orthogonal radiograph
. Failure to obtain radiographs of the contralateral limb
. Failure to use a "hot" light
. Failure to consult normal radiographicanatomy sources.

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 -

mineralizations should not be mistaken for al'ulsions or fracture

fragments(seeTable 16-3). In young, rapidly growing dogs,partic-
ularly the larger breeds, periosteal remodeling occurs along the
metaphysisof the long bones as it grows in length into the diaphy-
sis.This zone is calledthe "cut-back" zone and is the areaof active
osteoclasticactivity wherein the width of the metaphysis remodels
and reducesto the width ofthe diaphysis.This areacan be irregular
and scalloped and may reveal a degreeof periosteal reaction within
the soft tissues(Fig. 12-15), which is most pronounced along the
distal ulnar metaphysis.
Alternate imaging
Alternate imaging of the musculoskeletal system includes ultra-
sound, computed tomography, magnetic resonanceimaging, and
nuclear medicine. Ultrasound may be used to evaluate ligaments
and tendons in and around joints. Visualizationof the pattern of
a tendon or ligament can be done with minimal restraint, and
typically the opposite limb can be used for comparison.Some of
the standard areas evaiuated include the biceps tendon, common
calcanealtendon, and stifle joint (including evaluationof the me-
nisci). Evaluationof periostealsurfacesfor possiblepoints of aspi-
ration using ultrasound has also been describedin veterinary pa-
tients.'8
Computed tomography provides numerous advantagesin evalu-
ation of the musculoskeletalsystembecauseof its cross-sectional
imaging capabilities and enhanced contrast rendition. The use of
three-dimensionalimaging and multiplanar reconstruction pro-
r.ides a new wealth of information regarding a particular disease
and how the diseaseis impacting the anatomy're
Magnetic resonance(MR) imaging is the modality of choicefor
assessing articular and periarticular soft-tissueinjuries in humans.
Shoulder, elbow, carpal, and knee injuries are typically assessed
using MR imaging, and clear advancesin diagnosisand manage-
ment have been made. This is a relatively undefined area in veteri-
narv medicine, but in the future it is very likely the MR imaging
will assumea bigger role in the assessmentof canine and feline
joint injury.'?o'''
Nuciear medicine also provides the imager with unique informa-
tion for evaluating the musculoskeletal system."' 'Z3Technetium-
#r
Figure 12-15. Normalirreguarmargins alongthe metaphysis calledthe
"cut-back" zonewherethe metaDhvsisdecreasesthe overaI bonediameter
to the normaldraphysea bonediameter.
Themediolateralradrographof the
carpusshowsan irregular marginand mottedlucency associatedwlth the
ulnarmetaphysis.A retained coreis alsopresent
cartilage withinthe central
portionof thedrstaulnarmetaphyss.
99m can be tagged to methylene diphosphonate (MDP), which
then binds to the inorganic bone matrix in areas of active os-
teogenesis.Thesesitesof activenew bone turnovet can be detected
at much greatersensitivitythan is possibleusing radiographs.For
exampie,there must be a changein bone mass of at least 3070for
a change in radiographic opacity to be detectable.Physiologic
changes in blood flow or altered bone turnover can be detected
scintigraphically at a stage prior to actual radiographic opacity
changes.Nuclear medicine also provides a survey tool that can be
used to evaluate the entire skeleton with a minimum of radiation
exposure.
I Summary
Small animal musculoskeletal radiography presents a challenge in
that there is overlap of the radiographic appearanceof a variety of
diseaseetiologies.Lamenesslocalizationby the practitioner allows
radiographic assessmentof specificjoints and areasof the body.
Technical considerations include obtaining orthogonal views (with
or without oblique radiographs),the use of a detail film-screen
combination, and a low kilovoltage (kVp) and relatively high milli-
ampere second (mAs) technique. Comparison of possible radio-
graphic abnormalitieswith findings on radiographsof the opposite
Iimb and with anatomy textbooks can be important for accurate
assessmentof roentgen abnormalities.Characterizationof lesion
location, the number of bones involved, the extent of involvement
of a joint, and the spectrum of lytic and productive bone features
of aggressive or benign bone diseasecan lead to formulation of a
specificprimary differential diagnostic consideration,or a list of
differentials. Using the mnemonic of ABC'S, the reviewer should
 l n te rpretati on
P aradi gms
for the A ppendi cul ar
skel eton-cani neand Feline l4s

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.

12. Konde L: Interpretation of aggressivemusculoskeletal lesions. In Thrall DE (ed):

6. The parathyroid gland is responsible for:
Textbook ofVeterinary Radiology, 3rd ed. Philadelphia, WB Saunders, 1997. A. Activating osteoblasts and thus decreasing serum calcium
levels.
13. Thrall DE: Infection versus neoplasia of bones. In Thrall DE (ed): Textbook of
Veterinary Radiology, 3rd ed. Philadelphia, WB Saunders, 1997. B. Increasing calcium excretion by the renal tubules.
C. Decreasingconversion of Vitamin D. to the active form.
14. GoedegebuureSA: Secondarybone tumors in the dog. Vet Pathol 1,6:520,1979.
D. Increasing calcium absorption from the gastrointestinaltract.
15. Rogers KS, lanovitz EB, Fooshee SK, et al: Lymphosarcoma with disseminated
skeletal involvement in a pup. J Am Vet Med Assoc 19511242,1989
7, Each of the following radiographic changes is considered an
16. Hahn KA, Matlock CL: Nasal adenocarcinoma metastatic to bone in two doss. I aggressiveappearanceof a lesion, except:
Am Vet Med Assoc 197:491,1990.
A. Permeativeosteolysis.
17. Susaneck Sf, Macy DW: Hlpertrophic osteodystrophy. Comp Contin Educ Small B. Amorphous new bone formation.
Anim Pract 4:689. 1982. C. Lack of change in the radiographic appearance over a 3-
18. Samii VF, Nyland TG, Werner LL, Baker TW: Ultrasound-guided fine-needle week time course.
aspiration biopsy of bone lesions: A preliminary report. Vet Radiol Ultrasound 40;82, D. A long zone of transition between the center of the lesion
1999.
and the perceivedperipheral margin of the lesion.
19. Stickle RL, Hathcock lT: Interpretation of computed tomographic images. Vet
Clin North Am Small Anim Pract 23:417,1993.
8, A spiculated periosteal reaction seen along the diaphysis of
20. Banfield CM, Morrison WB: Magnetic resonance arthrography of the canine stifle long bones, particularly the distal long bones, is characteristicof
joint: Technique and applications in eleven military dogs. Vet Radiol Ultrasound
what disease?
41:200,20O0.
A. Hypertrophic osteodystrophy
21. Widmer WR, Buckwalter KA, Braunstein EM, et al: Resonance imaging of the B. Bone infarct
stifle joint in experimental osteoarthritis of dogs. Vet Radiol Ultrasound 35:371, 1994.
C. Hypertrophicinfarction
22. Innes lF, Barr ARS, Paterson MW, Dieppe PA: Scintigraphy in the evaluation of D. Hypertrophic osteopathy
osteoarthritis of the canine stifle joint: Relationship with clinical, radiographic and
E. Bone osteodystrophy
surgical observations. Vet Comp Orthop Trauma 9:53, 1996.

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.'.

With osteochondrosis of the lateral trochlea of the talus, the
superimposed calcaneusmay obscure the lesion in the dorsoplantar
view. In this instance, a dorsolateral-plantaromedial oblique, or a
flexed dorsoplantar, view can be acquired to provide an unob-
structed view of the lesion. In the stifle, the fossa for the origin of
the long digital extensor muscle is sometimes mistaken for a lateral
femoral condyle osteochondrosis lesion becauseit is superimposed
on the dorsolateral aspect of the condyle on both the lateromedial
and the caudocranial views.
Cartilage flaps are not visible on survey radiographs unless
calcification or ossification of the fragment has occurred. When a
nonmineralized cartilage fragment is present, an arthrogram can
be used to outline the flap, if contrast medium dissectsbetween
the fragment and the underlying subchondral bone. Arthrography
may also define migrating intra-articular cartilage fragmentsll'12
(seeFig. 13-1C). Newer nonionic and low-osmolar-contrastmedia
provide significantly better arthrographic quality than hyperosmo-
lar, ionic contrast media do becausethe contrast medium is not
diluted as quickly from fluid flux into the joint space.'3However,
becausearthroscopyhas gained acceptancefor the diagnosisand
definitive treatment of osteochondrosis,arthrography is now used
lesscommoniy.t',tt
Diseasesof the lmmatureSkeleton 147
Figure 13-1. Osteochondrosis of the shoulder.A, A well-de-
fi ned, mi neral i zedcarti l agefl ap i n the caudal humeral head
(arrow).The subchondralbone is nonuniformlyscleroticand has
an i rregul armargi n.Gas i vacuumsi gn) i s presenti n the j oi nt
space.Nitrogenhas accumulatedowing to negativeintra-articular
pressurefrom limb traction.Negativecontrastfrom the gas has
resul tedi n vi sual i zati on
of artl cul ar
carti l age
crani alto the fl ap.B ,
A sl i ghtl yfl attenedcaudalhumeralhead,but no obvi ousfl ap. l n
an arthrogram/CJon the same shoulderas that in B, contrast
medium dissectsbeneatha cartilageflap (arrows).
Elbow dysplasia
Elbow dysplasiais a nonspecific term referring to a triad of devel-
opmental lesions that include ununited anconeal process, frag-
mented medial coronoid processof the ulna, and osteochondrosis
of the distomedial aspect of the humeral trochlea. Although osteo-
chondrosis has previously been implicated as the cause of all three
of these disorders, asynchronous growth of the radius and ulna
and proximal ulnar dysplasia resulting in an elliptically shaped
ulnar notch have more recently been suggested as implicating
factors.3'tu t0 Elbow joint incongruity may result in nonuniform
contact of articulating surfaces,Ieading to nonunion of the anco-
neal processor separationof the medial coronoid process.re,2r One,
two, or all three of the primary lesions may be present in the same
animal, and both elbow joints are commonly affected.
Ununited anconeal process
Large-breed dogs that normally have a separateanconeal ossifica-
tion center early in development are at greater risk for ununited
anconeal process (Fig. 13-5). German shepherd dogs are over-
represented,although the lesion occurs in other breeds as wel1.The
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).

Figure 13-5. Ununlted process.
anconeal Arrowsoutlinetheanconealproc-
ess,whichis separate
fromtheproximal
ulna.Thebonemargins at thesrteol
separation
aresmoothandsclerotic,
suggesting
chronicity.
ulna by 150 daysofage. The anconealcenterofossification fails to
fuse by this time in dogs with ununited anconeal process.A flexed
lateral radiograph in addition to routine lateral and craniocaudal
views of the elbow should be included in the radiographic examina-
tion. The flexed lateral view dispiacesthe medial epicondylar physis
away from the anconeus,thereby decreasingthe possibility that an
overlying epicondylar physeal line may be confused with an un-
united anconealprocessmargin.
Radiographic srgns. The primary radiographic finding is best
seenon the lateral view and consistsof a radiolucent line separating
the anconealprocessfrom the olecranon in dogs older than 150
days. This lucent line can be sharply defined, or it may appear
irregular and of variable width. Degenerativejoint diseaseof the
elbow is a common sequel,and periarticularnew bone production
from osteoarthrosismay partially obscure the lucency between the
ulna and the anconealprocess.22-2a
Fragmented medial coronoid process
Fragmentedmedial coronoid processis the most common develop-
mental disorder involving the elbow joint. It primarily affectsmedi-
um- and large-breed dogs and has a significantly higher incidence
in males. Clinical signs may be apparent as early as 4 to 6 months
of age. Radiographic visualization of the coronoid fragment is
usually not possibleowing to superimpositionof the medial coro-
noid processon the radius, superimposition of proliferative new
bone from degenerative joint diseaseon the coronoid fragment, or
failure of the x-ray beam to strike the fragment plane in a parallel
fashion (Fig. 13-6). In addition, coronoid fragments that consist
mostly of cartilage or that are still partially attached cannot be
seen.In most instances,the radiographicdiagnosisof fragmented
medial coronoid processis made indirectly through the recognition
of secondary degenerativechangesthat accompany the primary le-
sion.
Both a neutral lateral and a craniocaudalradiograph of both
elbow joints should be made. In addition, a flexed lateral radio-
graph facilitates visualization of new bone formation on the proxi-
mal margin of the anconeal process. Flexing the elbow, however,
induces a mild degree of rotation that can partially obscure the
medial coronoid margin. A cranial 25-degreelateral-caudomediai
oblique view can also be obtainedto highlight the medial coronoid
region and fragmentedcoronoid process.2s Although joint incon-
eruity can be seenin associationwith fragmentedcoronoid process,
caution should be used to prevent over-readingof this finding. On
D i seasesof the l mmatureSkelet on l4g
the lateral view, the normal overlapping lucent lines representing
the complex elbow joint margins can be confused with jolnt incon-
gruity when even mild positioning obliquity is present. Computed
tom,ography is now being regularly used to diagnose fragmented
medial-coronoid processand is more sensitivethan survey radiog-
raphy for detecting the coronoid fragment.26-28
Radiographic signs. Primary radiographic signs include an
abnormal contour, or poor definition, olthe cranial margin of the
medial coronoid process on the lateral view. Often thi margin,
which is radiographicallydistinct in normai dogs, cannot be followed
proximally to the articular surfacein affectedanimals.On the cranio-
caudal vieq the medial margin of the medial coronoid processmay
appear blunted or rounded. A separateosseousbody. iepresenting
the fractured coronoid process,is only rarely seen.Joint incongruit|
or.subluxation may also be present and appears as a ,,stair-step;,
lesion between the ulna and the radial heid on the lateral view.
Secondaryradiographic signs include osteophlte formation on the
proximal margin of the anconealpto..., u, olr. of the earliestsigns
of degenerativejoint disease.Similar new bone is often present-on
the caudal surfaceof the lateral epicondyle.Subchondralbone sclero-
sis also develops adjacent to the trochiear notch and the proximal
radioulnar articulation near the lateral coronoid process.Tlese sec-
ondary findings are best appreciated on the lateral view. A large
osteophlte may arise from the medial coronoid margin on the
craniocaudalview, in addition to the more generalizeddegenerative
periarticularosteoph)'te production.,r.:q :-.:ol'o
|s_ep-trgnecrosis of the femoral head (Legg-
Galv6-Perthes disease)
Aseptic necrosis of the femoral head occurs in adolescenttoy and
small-breeddogs (Fig. 13-7). Compromised blood supply to the
femoral capital epiphysis causesnecrosisof subchondral-bonewhile
overlying articular cartilage continues to grow. Revascularization
occurs in an attempt to repair the defect, and removal of necrotic
bone causesdecreasedopuiity in the affectedfemoral head.Incom-
plete removal of necrotic bone and invasion of sranulation tissue
interfere with healing, resulting in a misshaperifemoral head of
r,
nonuniform oDacitv.3,'
. ladlographic signs. As with many of the other developmental
skeletal disorders, the radiographic findings of aseptic necrosis of
th-efemoral head vary with the duration of the lesion. Radiographs
of the hip joints may appear normal early in the course bf ihe
disease.Early in the progressionof the disease,linear lucenciescan
be detected within the subchondral bone deep within the femoral
head. Areas of decreased opacity may also appear in both the
femoral epiphysis and the metaphysis. Fiattening and irregularity
of the femoral head and neck become apparent as the iffected
bone remodelsand collapsesupon itself.Remodelingof the femoral
head may causecoxofemoral joint spacewidening and subluxation.
Fragmentation of the femoral head may eveniually occur from
pathologic fracture. Muscle atrophy and radiographic findings asso-
ciated with degenerativejoint diseaseusually develop.
I Disorders primarily affecting
I bone
Agenesis or malformation of single or
multiple bones
Agenesis and hypoplasia
Complete agenesis,partial agenesis,or hypoplasiaof a long bone
may occur (Fig. 13-8). The radius, tibia, and ulna are most often
involved, although the metacarpal and metatarsal bones can also
be affected. These anomalies, which can usually be detected at or
shortly after birth, may be inherited but are more often a result of
rn utero environmental factors.
Radiographic srgns. The affected bone or bones are conspicu-
I5 0 S KE L ET ON -C A N INAEN D FE LIN E
A P P E NDI C U L AR

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 13-6 Continued. E Fragmentation of the coronoidprocesscan occasionally be seen on a craniolateral,

caudomedialobliqueview (arrow).F,A computed
tomographyimageof the elbow from a dog with a fragmentedmedialcoronoidprocessand degenerative joint disease.The fragmentedcoronoidprccess@rrow)
, e b a sila pr a r to f th e co r o n o idp r o c essi s scl eroti cand remodel ed.
is e a s i l ys e e n .I n a d d itio nth

Figure 13-7. Aseptic necrosisof the left femoral head.The femoral head
containsa largeradiolucentarea with surroundingsclerosis(arrows).There is
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
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.
Figure 13-8. llbial agenesisin a young dog. The tibia is not formed, and
the fi bul ai s mi sshapen. The proxi mal fi bul arepi physi iss hypopl as tiand
c poorl y
mi neral i zed. l i bi ai agenesi shas l ed to sti fl eand tarsocrural oi
l nt mal formati on
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
normal. Limb curvature and ioint malformation may also be pres-
ent.
Polymelia
This general term denotes suPernumerary limbs or parts of a limb'
Polydictyly, the presenceof an excessnumber of digits, is the most
common fot- of polymelia and is most often seen in cats. A few
breeds of dogs, su-h as the Great P1'renees'have also been bred to
retain this triit. The anomaly is generally clinically insignificant'
Radiographic srgns. Radiographic signs of polymelia vary ac-
cording to the bone or bones involved. Findings of polydactyly
include a greater-than-normal number of digits, usually arising orr
the medial side of the limb. Supernumerary digits may include
complete or partial metacarpal/metatarsalbones and variable num-
bers of phalanges.
Disorders of unknown etiology
Panosteitis
Panosteitis is a self-limiting diseasethat affects the long bones of
primarily young, large-breed dogs (Fig. 13-9). Males are affected
iour times more often than femaiesand the lesion is most common
in German shepherd dogs. Dogs betrveen the ages of 5 and 12
months are most often affected; however, afflicted dogs as young
as 2 months of age and as old as 7 yearsof agehave been reported'
Panosteitis lesions may be solitary, may affect multiple sites in a
single bone, or may be multifocal in multiple bones. Although the
lesi-onscan affect any part of the diaphysis of a long bone, they
often originate and are most pronounced near the nutrient fora-
men. Bone involvement is often sequential and the diseasemay be
protracted over several months, with lesions resolving in some
areas while developing in others' Severity and location of radio-
graphic lesions do not necessarily correlate with- the severity of
ili.ri.ul rignt, and the most clinically affected limb may not have
the most pronouncedradiographiclesions.33'3a The term panosteitis
is a misnomer in that histologically there is no evidence of an
Figure l3-9. Stages of panosteitis.A, Early stage in a femur. There is circumscribedincreasedopacity in the mid-diaphysisand the
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
. 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)
inflammatory response. Microscopically, there is an increase rn
medullary, endosteal,and periosteal osteoblasticand fibroblastic ac-
tivity.
Radiographic srgns. Very early in the course of the disease'
blurring and accentuation of trabecular bone of the affected long
bone are noted. Circumscribed nodular opacities similar in opacity
to cortical bone form within the diaphyseal medullary cavity of
long bones,often near nutrient foramina. As the lesion progresses,
medullary opacities become more diffuse and homogeneous.
Smooth, continuous periosteal new bone formation develops in
the diaphysis of affected bones in one third to one half of dogs.
Late in the disease, opacities resolve, leaving coarse, thickened
trabecular bone that eventually assumes a normal appearance.
Cortical thickening may persist as periosteal new bone remodels.
Hypertrophic osteodystrophy
Hypertrophic osteodystrophy is a systemic illness that usually af-
fects large- and giant-breed dogs that are between the ages of 2
and 7 months. The cause is unknown, but oversupplementation
of minerals and vitamins, hlpovitaminosis C, and suppurative
inflammation without isolation of infectious agents have all been
proposed.tt-t More recently, canine distemper virus has been iso-
lated from metaphysealbone celis in affected animals and has been
suggestedas a causative factor.a2aa Clinical signs, including marked
pyrexia, diarrhea, footpad hyperkeratosis,leukocl'tosis,anemia, and
pneumonia, are occasionally seen with hlpertrophic osteopathy,
lending credibility to the possibiiity of a systemic infection as a
causefor this disease.at
Resulting bone lesions are generally bilaterally symmetric and
involve the metaphysesof long bones, particularly the distal radius,
ulna, and tibia (Fig. 13-10). The costochondral junctions, the
metacarpal/metatarsalbones, and the craniomandibular region may
also be involved. Craniomandibular osteopathy may, in fact, be
a different clinical manifestation of hlpertrophic osteodystrophy.
Although the diseaseis usually self-limiting and resolvesafter a few
weeks, more severeinvolvement can ultimately result in abnormal/
premature physeal closure and subsequentskeletal deformity. His-
proximaldiaphysis
periostealnew bone formationon the diaphysis.C Later
t opaci typri mari l yi n the proxi malradi usand ul na.There i s mi l d peri os tealnew bone
 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-

tologically, lesions in the metaphyseb consist of a neutrophilic

inflammatory responseassociatedwith necrosis, hemorrhage, and
increased osteoclast numbers. Collapse of necrotic metaphyseal
trabecularbone and subperiostealhemorrhageare also seen."
Radiographic signs. Early radiographic signs include trans-
verselyoriented lucent zoneswithin the metaphysisthat are parallel
and adjacent to the physes.These are usually best seenin the distal
radius and ulna, and this appearanceis sometimes referred to as
the "double physis" sign. A thin margin of subchondral bone
sclerosis may parallel the lucent zone and is due to collapse of
necrotic trabecular bone. Irregular periostealnew bone forms
around the metaphysis and is usually distinct and separate from
the underlying cortex in the earlier stagesofthe disease.The extent
of new metaphysealbone formation depends on the severity and
duration of the disorder, and such formation may extend to the
diaphysis in severelyaffected dogs. Diffuse soft-tissue swelling can
be seencentered on the metaphysealregions. There may be widen-
ing, concavity, and increased opacity of the distal rib ends in
some oogs.

Metabolic and generalized bone disorders

Nutritional secondaryhyperparathyroidism
Nutritional secondary hyperparathyroidism is caused by a diet
that is either calcium deficient or calcium:phosphorus imbalanced.
Inadequatedietary calcium intake causesan increasein parathyroid
hormone. This in turn results in bone calcium resorption and
generalizedosteomalacia(Fig. 13-11). The skeletal changesare
diffuse and generalized.36,a5,a6
Radiographic signs. There is a generalized decreasein bone
opacity, and cortices may appear abnormally thin. In severely
affected animals, bone opacity may be similar to that of soft tissue.
There may also be a loss of definition of the normally densedental Fi gure 1 3-1 1. N utri ti onalsecondaryhyperparathyroi di s m. Ov eral lbone
opaci tyof the femur i s decreased,and corti cesare thi n. A n ooaouel i ne i n
lamina. Spinal deformity and pathologic folding fractures of the the di staltemur (arrow )w i th angul ati onat thi s si te Indi c atesa pathol ogi c
appendicular and the axial skeleton are common. fol di nqfracture.
 S KE L ET ON -C A N INAEN D FE LIN E
I5 ,4 A P P E NDI C U L AR

e,+ S ts -i
'
- J- - :- ;;- ": ,

Figure 13-13. Laterallumbarspineof a cat with mucopolysaccharidosis.

Thevertebral diskspacesarewiderthan
bodiesareshortand intervertebral
normalowingto delayed endplatemineralization dysplasia.
from epiphyseal
Similar werepresent
findings in theepiphysesof longbones.

Radiographic srgns. There is a generalized decreasein bone

opacity, and long bone cortices are thin. Pathologic fractures are
common and may be associatedwith excessivelyopaque callus
formation and medullary sclerosis.Findings are similar to and can
be confused with generalized bone mineral loss from secondary
hyperparathyroidism.

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

Figure 13-12. Congenital hypothyroidism immaturedog.

in a skeletally
Mrneralization andcuboidbonesof the carpus
of the longboneepiphyses is
markedly reduced. (FromSaundersH:Theradiographic of canine
appearance
congenital hypothyroidism: changes
Skeletal with delayed Vet Fa-
treatment.
diol3 2:1 71 ,19 91 .)

charidosis involve both the axial and the apPendicular skeleton.

There is generalizedepiphysealdysplasiainvolving long bones and
vertebral end plates. Findings include delayedand incomplete min-
eralization of the epiphyseal cartilage model. Ossified regions of
the epiphyses are smaller than normal and have a nonuniform
opaciiy with a granular appearance.Vertebral bodies appear cubo,id
and shorter thin normal. The maxilla is short and flattened; the
frontal sinuses may be small or absent. Progressivedegenerative
ioint diseaseoccurs as a sequel to the epiphyseal malformations.
Hip subluxation or luxation may result from femoral head epiphy-
sis remodeling. Ventral, bridging spondylosis is seen in older ani-
mals.--

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

number of normal hematopoietic cells subsequentlyoccurs, leading

to myelophthistic anemia.
Radiographic srgns. There is a generalized increase in bone
opacity, particularly in medullary cavities. The normal trabecular
pattern is diminished owing to the uniform increase in bone
opacity, and the internal cortical margins become indistinct. In
some animals, the medullary cavity retains normal opacity in the
central diaphysealregion.

Metaphyseal and epiphyseal dysplasias

Osteochondraldysplasias
Osteochondral dysplasiasinclude chondrodysplasia,osteochon-
drodysplasia,enchondrodystrophy, multiple enchondromatosis,
oculoskeletaldysplasia,hypochondroplasia, multiple epiphyseal
dysplasia,and pseudoachondroplasia.Chondrodysplasiaand osteo-
chondrodysplasia result in disproportionate dwarfism and have
been reported in a number of breeds,including Alaskan malamutes,
Norwegian elkhounds, Great Pl.renees,Scottish deerhounds, Bull
terriers, and Scottish Fold cats.63to Similar disorders have been
described in Irish setters (hypochondroplasia),English pointers
(enchondrodystrophy), and Miniature Poodles (multiple enchon-
dromatosis). Chondrodysplasia associatedwith ocular defects has
been described in Labrador retrievers, Samoyeds, and German
shepherd dogs. Although these disorders may sometimesappear
clinically and radiographically similar, they represent a histologi-
cally and biochemicallyheterogeneous group ofdiseases.Character-
ization is further complicated by the variety of classificationsystems
that were used to describe these lesions when they were originally
reported.
In almost all instancesin which microscopic findinss have been Figure 13-15. Chondrodysplasia in an Alaskanmalamute.Thedistalulnar
described, markedalterationsin chondrocytemorphol-ogy metaphyssis flattened,
andthe physisis muchwiderlhan normal(arrow).
and car- Thecarpal
bonesaresmaller in sizethanthosein normal
littermates.
tilage architecture are present. Although many of these disorders
are inherited and known to be sinsle autosomal recessivedefects.
othershave not beenadequarely ch"aracterized. In some instances,
the genetic defect can also be variably expressed,resulting in a delayedunion ofvertebral end plates.Costochondral junctions may
wide variation in severity of clinical signs. It is important to be prominently flared and cupped. The skull appearsradiographi-
distinguish betweenchondrodystrophoid dogs, those that have been cally unaffected.
bred for many generationsto establisha defect as a breed character-
Osteochondrodysplasia of Scottish Fold cats
istic, and chondrodysplastic dwarves that sporadicaily arise from
This disorderis probably due to a simple autosomaldominant trait
normal parents. Following are representativedescriptions of some
that is expressedto some degreein cats displaying the characteristic
of theselatter disorders.
folding of the pinna (Fig. 13-16). Affected animals are shorter
Chondrodysplasia of Alaskan malamutes than normal, have difficulty supporting their weight, have gait
This disorder is transmitted by an autosomal recessivegene, and abnormalities, and have a thick, inflexible tail base. Lesions are
skeletal abnormalities are accompanied by a macrocytic hemolytic radiographically evident by 7 weeks of age.
anemia (Fig. 13-15). Limb shortening with cranial and lateral Radiographic srgns. Metaphysesof the metatarsalsand meta-
deviation of the forelimbs and enlarged carpi are common clinical carpals are distorted and physes are widened. Similar but less
signs.Abnormalities appear to be limited to the long bones and the pronounced abnormalities are seen involving the phalanges.Short-
cuboid bones. The skull and spine are radiographically unaffected. ening of the metacarpi, metatarsi, and phalanges results in de-
Radiographic srgns. Al1 appendicular growth plates can be creasedlimb length. Punctate lucencieswithin the carpal and tarsal
affected,but lesions are best seenin the distal ulnar physis and the bones may also be seen. Caudal vertebrae are reduced in length
metaphysis. The distal metaphysis of the radius is flared, and the and have widened end plates. Secondary degenerativejoint disease
border is irregular. Trabecular bone is coarseand disorganized,and invariably develops and leads to carpal or tarsal ankylosis in se-
cortices appear thin. Asynchronous growth of the radius and ulna 73
verely affected cats.72,
produces angular limb deformities. Radiographic changesmay be
Ocular chondrodysplasia of Labrador retrievers
detected in dogs as early as 7 to 10 days of age but can be more
66,68,71 Ocular chondrodysplasiaalso appearsto be an uncommon autoso-
definitivelydiagnosedbetween5 afld 12 weeksof age.64'
mal recessive inherited chondrodysp1asia.63,66,6e
In addition to tlpi-
Chondrodysplasia of Norwegian elkhounds cal skeletal changes,ocular manifestations include cataracts,retinal
This is an autosomal recessivedisorder of variable expressivitythat dysplasia,and retinal detachment.
appearsto be fairly widespread.6s,66,68As with other chondrodys- Radiographic srgns. Long-bone shortening is seen, specifically
plasias, this disorder produces disproportionate dwarfism but the involving the radius and ulna, and is associated with delayed
front limbs may be more affected than the hindlimbs. Unlike the growth of the anconeal and coronoid processesof the ulna and the
disorder affecting Alaskan malamutes, this diseasealso affects the medial epicondyle of the humerus. Cortical opacity and thickness
axial skeleton. are reduced,and a retained cartilagecore is sometimespresentin
Radiographic srgns. Long-bone abnormalities may appear sim- the distal ulna. Flaring of the ulnar metaphysis and widening of
ilar to those of Alaskan malamute chondrodvsolasia. Forelimb the adjacent growth plate occur. There is an increasein the opacity
curvature may be evident by 5 weeks of age.Spinafchangesinclude of the primary spongiosain all metaphyses.Retardedand asynchro-
lipping and pleating of the ventral vertebral body margins and nous radial and ulnar elongation leads to developmentof radius
I5 6 R EL E T O N -C A N INAEN D FE LIN E
A P P E NDI C U L ASK

Fi gurc 13-16. S cotti shFol d osteochon draldy s pl as i a.

Metatarsalbones are short and mi sshapen.Phal anges al s o
appear to be affected. Marked secondarydegenerati v e
changesare presentat al l l evel sfrom the tars oc ruraloi nt
j
distally.The large mass of new bone in the plantarolateral
aspectof the l i mb contri butesto cuboi dalbone fus i onand
tarsalankyl osi s.

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

Multiple cartilaginous exostosis

Multiple cartilaginous exostosisis a benign proliferative diseaseof
bone and cartilage (Fig. 13-18). Hereditary transmission of the
diseaseis suspectedin dogs.tt Any bone that developsby endochon-
dral ossification may be affected, and simultaneous involvement in
multiple bones is common. Chondrocytes are pushed into the
metaphysesand do not differentiate into osteoblasts.Instead, these
cartilage islands continue to proliferate as cartilaginous massesthat
eventually ossify. Growth usualiy ceasesonce the animal has
reachedmaturity, resulting in nonpainful bony protuberances Figure 13-17. Epiphysealdysplasiain a 2-month-oldBeagle.The distal
throughout the skeleton. The bone lesions are of no clinical sig- humeralepi physi sconsi stsof rounded,scl eroti ccentersof bone formati on.
nificance unless they arise in an area in which function might be The proxi malradi aland ol ecranon
physeshavea normalappea ranc e.
 Diseasesof the lmmatureSkeleton 1|57

radiolucency and bone opacity with irregular contours. Long-bone

and vertebral masses tend to be more organized in appearance
with radiolucent cartilage and trabecular bone. Cortical bone in
the area of the lesion may be present or absent; the bone may be
deformed, or the exostosis may project externally. The size and
shape of exostosesare variable.

Retained caftilage cole

Retained cartilage cores are seen primarily in the distal ulnar
metaphysisoflarge-breed dogs, although they are occasionallyseen
in the lateral femoral condyle",8n(Fig. 13-19). The lesion is caused
by a disruption of the normal progression of endochondral ossifi-
cation with retention of hypertrophied cartilage cells in the central
metaphysis. Cartilage retention may cause angular limb deformity
due to retardation of distal ulnar growth and a resulting mismatch
in radial and ulnar elongation, but the lesion is sometimes an
incidental finding in otherwise normal dogs.
Radiographic srgns. Primary radiographic findings include the
presence of a cone-shaped radiolucent area in the distal ulnar
F i g u r e 1 3 - 1 8 . M ultip leca r tila g in o uesxo sto sis. T wo la r g e expansi
, l leesi ons
are presentinvolvingthe third and seventhribs (largearrowheads). The opacity metaphysis or lateral femoral condyle. A narrow zone of sclerosis
i s m i x e db o n ea n ds o ft tissu e .M u ltip len o d u labr o n em a sse sdeformthe shape may surround the radiolucent area. Additional radiographic find-
of the thoracicspinousprocesses(smallarrowheadsl.An incidentafinding is ings may include angular limb deformity and degenerativejoint
+ ho nr oc onno
^f
r ^. Le . ., a-.omacn
n +h a i {openarrow). diseaseof the elbow and carpal joints.

Incomplete ossification of the humeral condyle

multiple cartilaginousexostoses.A similar disorder is seenin ma-
ture cats, and a viral etiology has been proposed.T3'7e In cats
however, the disorder tends to be progressive,resulting in clinical
signsrelatedto pain and ioss of function.
Radiographic signs. Rib massesare an amorphous mixture of
in spaniels
Incomplete ossification of the humeral condyle is a heritable condi-
tion of pure-bred and cross-bredspaniels,resulting in a higher-
than-normal incidence of humeral condylar fractures associated
with normal activitfs (Fig. 13-20). The incidence of the disorder

au:,t€ut:rutau:u
rlsl
r,.l13rrr,:iisrir
ilr1r13
:iiioul
9.aa:,:::i

Figure 13-19. Retainedcartilagecore in the distalulna.A triangularradiolu-
cent region is present in the distal ulnar metaphysis(arrows).A thin rim of
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
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
r e s ut i n g f r o m d e l a y e du ln a rg r o wth .
Figure 13-2O. Incompleteossificationof the humeralcondyle.A vertica
radiolucentline is presentin the distalhumeralcondyle(openarrow).Periosteal
new bone formationls presenton the distal lateralhumerus (curvedarrow),
probabl ysecondary to moti onfrom an i ncompl etefractureex tendi ngl ateral l y
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
appearsto be higher in males.There are sporadic reports of other
medium- and large-breed dogs being affected by this disorder.s6
There are normally two separate centers of ossification in the
humeral condyle that appear by approximately 22 daysafter birth.
The mediai and lateral centers of the condyle should fuse by about
84 days after birth. Incomplete ossification leads to the presenceof
a thin fissure separating the medial and lateral halves of the hu-
meral condyle in skeletallymature dogs. When pathologic fractures
occur, about half are "Y"- or "T"-type fractures affecting the entire
epicondylar region; the remainder are limited to fractures of the
lateral (35%) or medial (15%) condyle.8'The incidenceof incom-
plete humeral condylar ossif,cation is high enough that bilateral
elbow radiographs should be obtained in any spaniel with a unilat-
eral condylar fracture. There also appearsto be an increasedinci-
denceof fragmentedcoronoid processes associatedwith this disor-
Radiographic srgns. The primary radiographic finding in dogs
with incomplete humeral condylar ossification is a vertically ori-
ented radiolucent line in the central region of the condyle that may
extend from the subchondral bone margin of the trochlea to the
distal margin of the supratrochlear foramen. This lucency is evident
only on the craniocaudal view and may be better seen when
the view is obliqued approximately 15 degrees craniomedial to
caudolateral, which positions the fissure parallel to the x-ray beam
angle.Secondaryradiographicsignsinclude smooth periostealnew
bone formation along the lateral and caudal aspectof the humeral
epicondylar region. This finding may be a response to chronic
instability or incomplete, nondisplaced fracture through the nonos-
sified region. Overt, displaced pathologic condylar fractures may
be presentin one or both limbs.
Radiographic evidence of concurrent fragmented medial coro-
noid processmay be present.
References
1. Ekman S, Carlson CS: The pathophysiology of osteochondrosis. Vet Clin North
Am Small Anim Pract 28:17-32, 1998-
2. Smitach L, Stowater T; Osteochondritis dissecansof the shoulder joint: A review
of 35 cases.J Am Adm Hosp Assoc Il:658-662, 1975.
3. Olsson S-E: The early diagnosis offragmented coronoid processand osteochondri-
tis dissecansof the canine elbow joint. J Am Anim Hosp Assoc 19:616-626, 1983.
4. Alexander ], Richardson D, SelcerB: Osteochondritis dissecansof the elbow, stifle
and hock-a review J An Anim Hosp Assoc 17:51 56, 1981.
5. Denny H, Gibbs C: Osteochondritis dissecansof the canine stifle joint. I Small
Anim Pract 2l:317-322, 198O.
6. Fitch RB, Beale BS: Osteochondrosis of the canine tibiotarsal joint Vet Clin North
Am Small Anim Pract 28:95-113, 1998.
7. lF.ara:i l: Osteochondrosis of the femur. Vet Clin North Am Small Anim Pract
28:87-94,1998.
8. Poulos PW h: Canine osteochondrosis. Vet Clin North Am Small Anim Pract
12:313-328,1982.
9. Wisner ER, Berry CR, Morgan lP, et al: Osteochondrosis of the lateral trochlear
ridge of the talus in seyen Rottweiler dogs. Vet Surg 19:435-439, 1990.
10. van Bree H: Evaluation of subchondral lesion size in osteochondrosis of the
scapulohumeral joint in dogs. I Am Vet Med Assoc 204:1472-1474, 1994.
11. van Bree H: Evaluation of the prognostic value of positive-contrast shoulder
arthrography for bilateral osteochondrosis lesions in dogs. Am I Vet Res 51:1121
1125, 1990.
12. van Bree H: Comparison ofthe diagnostic accuracy ofpositive-contrast arthrogra
phy and arthrotomy in evaluation of osteochondrosis lesions in the scapulohuneral
joint in dogs. I Am Vet Med Assoc 203:84-88, 1993.
13. van Bree H, Van Rijssen B, TshamalaM, Maenhout T: Comparison of the nonionic
contrast agents, iopromide and iotrolan, for positive-contrast arthrography of the
scapulohumeral joint in dogs. Am J Vet Res 53:1622-1626, 1992.
14. Bertrand SG, Lewis DD, Madison JB, et al: Arthroscopic examination and treat-
ment of osteochondritis dissecans of the femoral condyle of sit dogs J Am Anim
Hosp Assoc 33i45I-455, 1997.
15. van Bree H], Van RyssenB: Diagnostic and surgical arthroscopy in osteochondro-
sis lesions.Vet Clin North Am Small Anim Pract 28:161-189,1998.
16. Boudrieau R, Hohn R, Bardet J: Osteochondritis dissecansof the elbow in the
dog. i Am Anim Hosp Assoc 19:627-635,1983.
17. Goring R, Bloomberg M: Selected developmental abnormalities of the canine
elbow: Radiographic evaluation and surgical management. Compend Cont Ed Pract
Vet 5:178 188, 1983.
18. Mason T, Lavelle S, Skipper S, et al: Osteochondrosis of the elbow joint in young
dogs.J Small Anim Pract 2l:641-656, 1980.
19. Wind A: Elbow incongruity and developmental elbow diseasesin the dog: I. J Am
Anim Hosp Assoc22i711-724,1986.
20. Wind A: Elbow incongruity and developmental elbow diseasesin the dog: II. J
Am Anim Hosp Assoc 22:725,1986.
21. Boulay J: Fragmented medial coronoid process of the ulna in the dog. Vet Clin
North Am Small Anim Pract 28:51-74, 1998.
22. Battershell D: Ununited anconeal process.J Am Vet Med Assoc 155:35, 1969.
23. Sjostrom L: Ununited anconeal process in the dog. Vet Clin North Am Small
Anim Pract 28:75 86, 1998.
24. Tirgari M: Clinical, radiographical and pathological aspects of ununited medial
coronoid process of the elbow .joint in dogs. I Small Anim Pract 2l:595-608, 1980.
25. Berzon J, Quick C: Fragmented coronoid process:Anatomical, clinical, and radio-
graphic considerationswith caseanalyses.I Am Anim Hosp Assoc 16:241-25I,1980.
26. Braden T, Stickle R, Dejardin L, et al: The use of computed tomography in
fragmented coronoid disease:A casereport. Vet Comp Orthop Trauma 7.40-44, 1994.
27. Hornof Wl, Wind AR Wallack ST, Schulz KS: Canine elbow dysplasia. The early
radiographic detection of fragmentation of the coronoid process.Vet Clin North Am
Small Anim Pftct 30t257-266,2000.
28. Reichle lK, Park RD, Bahr AM: Computed tomographic findings of dogs with
cubital joint lameness.Vet Radiol Ultrasound 41:125-130,2000.
29. Befiy C: Evaluation of the canine elbow for fragmented medial coronoid process.
Vet Radiol Ultrasound 33:273-274, 1992.
30. Read R, Wind A, Morgan J, Pool R: Fragmentation of the medial coronoid process
of the ulna in dogs: A study of 109 cases.I Small Anim Pract 31:330-334,1990.
31. Lee R: A study of the radiographic and histological changes occurring in Legg-
Calv€-Perthesdisease(LCP) in the dog. I Small Anim Pract 11:621-638,1970.
32. Lee R: Legg-Perthesdiseasein the dog: The histological and associatedradiological
changes.J Am Vet Radiol Assoc 15:24-27,1974.
33. Burt lK, Wilson GP: A study of eosinophilic panosteitis (enostosis) in German
shepherd dogs. Acta Radiol Suppl 319:7-13, 1972.
34. Bohning RH h, Suter PR Hohn RB, Marshall l: Clinical and radiologic survey of
canine panosteitis.) Am Vet Med Assoc 156:870883, 1970.
35. Grundalen J: Metaphyseal osteopathy (hlpertrophic osteodystrophy) in growing
dogs. A clinical study. J Small Anim Pract 17:721-735,1976.
36. Bennett D; Nutrition and bone diseasein the doe and cat. Vet Rec 98:313-32I,
1976.
37. Alexander JW: Selectedskeletal dysplasias:Craniomandibular osteopathS multiple
cartilaginous exostoses,and hypertrophic osteodystrophy. Vet Clin North Am Small
Anim Pract 13:55-70,1983.
38. Woodard JC: Canine hypertrophic osteodystrophy: A study of the spontaneous
diseasein littermates. Vet Pathol 19:337 354,7982.
39. Watson AD, Blair RC, Farrow BR, et al: Hypertrophic osteodystrophy in the dog.
Aust Vet J 49:433439, 1973.
40. Olsson S-E: Radiology in veterinary pathology. A review with special reference to
hlpertrophic osteodystrophy and secondary hyperparathyroidism in the dog. Acta
Radiol Suppl 319:255-270, 1972.
41. Muir P, Dubielzig R, Johnson K, Shelton G: Hypertrophic osteodystrophy and
calvarialhlperostosis.Compendium 18:143 151, 1996.
42. Baumgartner W, Boyce RW, Weisbrode SE, et al: Histologic and immunocyto-
chemical characterization of canine distemper-associatedmetaphysealbone lesions in
young dogs following experimental infection. Vet Pathol 32:702-709, 1995.
43. AbelesV, Harrus S, Angles JM, et al: Hlpertrophic osteodystrophy in six Weimara-
ner puppies associatedwith systemic signs. Vet Rec 145:130-134, 1999.
44. Mee AR Gordon MT, May C, et al: Canine distemper virus transcripts detected in
the bone cells of dogs with metaphyseal osteopathy.Bone 14:59-67, 1993.
45. Riser W: Radiographic differential diagnosis of skeletal diseasesof young dogs. J
Am Vet Radiol Soc 145:5-26,1964.
46. Voorhout G: IRadiographic features of nutritional secondary hlperparathyroidism
in the growing dog and cat.l Tijdschr Diergeneeskd106:317-324,1981.
47. Greco DS, Feldman EC, Peterson ME, et al: Congenital hypothyroid dwarfism in
a family of giant schnauzersfseecomments]. J Vet Intem Med 5:57 65, 1991.

48. Lieb AS, Grooters AM, Tyler lW, et al: Tetraparesis due to vertebral physeal
fracture in an adult dog with congenital hlpothyroidism. J Small Anim Pract 38:364
367, 1997.
49. Robinson WF, Shaw SE, Stanley B, Wyburn RS: Congenital hlpothyroidism in
Scottishdeerhound puppies.Aust Vet J 65:386-389,1988.
50. Saunders H: The radiographic appearance of canine congenital hlpothyroidism:
Skeletal changeswith delayed treatment. Vet Radiol 32:171-177, 199I.
51. Haskins M,JezykP, Desnick R, et al: Alpha-r-iduronidase deficiency in a cat: A
model of mucopolysaccharidosis:L Pediatr Res 13:1294-1297, 1979.
52. Haskins ME, Aguirre GD, lezyk PF, et al: Mucopolysaccharidosis tlpe VII (sly
spdrone). Beta-glucuronidase deficient mucopolysaccharidosis in the dog. Am J
P a th o l 1 3 8 :1 5 5 3 -1 5 55,
1991.
53. Haskins ME, Jezyk PF, Desnick Rl, et al: Animal models of mucopolysaccharidosis.
Prog Clin Biol Res94:177-201,1982.
54. Haskins ME, Otis El, Hayden lE, et al: Hepatic storage of glycosaminoglycans
in feline and canine models of mucopolysaccharidoses I, VI, and VII. Vet Pathol
29tII2-119, 1992.
55. Konde L, Thrall M, Gasper P, et al: Radiographic changes associatedwith muco-
polysaccharidosisin the cat. Vet Radiol 28:223-228, 1987.
56. Shull RM, Helman RG, Spellacy E, et al: Morphologic and biochemical studies of
canine mucopolysaccharidosisI. Am ) Pathol 114:487-495, 1984.
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.
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
slmdrome. Vet Pathol 35:230-233, 1998.
59. Campbell BG, Wootton JA, Krook L, et al: Clinical signs and diagnosis of os-
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).]
Acta Med Vet (Napoli) 14:79 109,1968.
61. Schmidt V: fOsteogenesis imperfecta in 2 collie litter siblings.] Wien Tierarztl
Monatsschr 54:92-100, 1967.
62. Lees GE, Sautter JH: Anemia and osteopetrosis in a dog. J Am Vet Med Assoc
175:820-824, 1979.
63. Carrig CB, MacMillan A, Brundage S, et al: Retinal dysplasia associated with
skeletal abnormalities in Labrador retrievers. J Am Vet Med Assoc 170:49 57,1977.
64. Terpin T, Roach MR: Chondrodysplasia in the Alaskan malamute: Involvement of
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
107:219-229, 1982.
66. Sande RD, Bingel SA: Animal models of dwarfism. Vet Clin North Am Small
Anim Pract 13:71-89, 1983.
67. Bingel SA, Sande RD, Wight TN; Chondrodysplasia in the Alaskan malamute.
Characterization of proteoglycans dissociatively extracted from dwarf growth plates.
Lab Invest 53:479-485,1985.
68. Minor RR, Farnum CE: Animal models with chondrodysplasia/osteochondrodys
plasia. Pathol Immunopathol Res 7:62 67, 1988.
69. Carrig CB, Sponenberg DP, Schmidt GM, Tvedten HW: Inheritance of associated
ocular and skeletal dysplasia in Labrador retrievers. J Am Vet Med Assoc 193:1269-
1272,1988.
70. Breur GL Zerbe CA, Slocombe RF, et al: Clinical, radiographic, pathologic, and
genetic features of osteochondrodysplasiain Scottish deerhounds. I Am Vet Med Assoc
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
radiographic pathogenesis.J Am Vet Radiol Soc l5tl0-I7, 1974.
i2. Malik R, Allan GS, Howlett CR, et al: Osteochondrodysplasia in Scottish Fold
cats. Aust VetI 77:85 92. f999.
;3. A.llan GS: Radiographic features of feline joint diseases.Vet Clin North Am Small
.\nim Pract 30:281-302,2000.
i4. Riser WH, Haskins ME, )ezyk PF, Patterson DF: Pseudoachondroplasticdysplasia
in miniature Poodles: Clinical, radiologic, and pathologic features. I Am Vet Med
. \sso c1 7 6 :3 3 53 4 1 , 1 9 80.
, 5. RasmussenPG: Multiple epiphysealdysplasia in a litter of Beagle puppies. J Small
{nim Pract 12:9\-96, I97I.
,6. RasmussenPG: Multiple epiphysealdysplasia in Beaglepuppies. Acta Radiol Suppl
319:251-254.I972.
D i seasesof the l mmatureSkelet on t 59
77. Rasmussen PG, Reimann I: Multiple epiphyseal dysplasia, with special reference
to histological findings. Acta Pathol Microbiol Scand (A) 8l:381-389, 1973.
78. Gambardella PC, Osborne CA, StevensIB: Multiple cartilaqinous exostosesin the
dog. I Am Vet Med Assoc166:7bl-768, t975.
79. Pool R, Harris J; Feline osteochondromatosis. Feline pract 5:24-30, 1975.
80. Doige C, Pharr J, Withrow S: Chondrosarcoma arising in multiple cartilaginous
exostosesin a dog. I Am Anim Hosp Assoc 14:605-611,1978.
81. Owen L: Multiple cartilaginous exostoseswith development of a metastasizing
osteosarcomain a Shetland sheepdog. J Small Anim pract I2i5O7-5I2, l97ir
82. Jacobson LS, Kirberger RM: Canine multiple cartilaginous exostoses: Unusual
manifestations and a review of the literature. J Am Anim Hosp Assoc j2:45-51, 1996.
83. lohnson KA: Retardation of endochondral ossification at the distal ulnar srowth
plate in dogs. Aust Vet J 571474-478,1981.
84. Riser W, Lincoln J, Rhodes W et al: Genu valgum: A stifle deformity of giant
dogs. I Am Vet Radiol Assoc 10:28-37,1969.
85. Marcellin-Little Dl, DeYoung DJ, Ferris KK, Berry CM: Incomplete ossification of
the humeral condyle in spaniels(seecomments).Vet Surg 23:475-487,1994.
86. Rovesti GL, Fluckiger M, Margini A, Marcellin-Little Dl: Fragmented coronoid
process and incomplete ossification of the humeral condyle in a Rottweiler Vet Surg
27:354-3s7,1998.
ffi Ouestions
l. True or False.Typical radiographic findings of osteochondrosis
include a flat or concave synchondral bone defect with a sur-
rounding scleroticmargin.
2. Tiue or False.Osteochondrosislesions are almost alwaysunilat-
eral.
3. The anconealprocessis consideredununited if separationof
the anconeus from the ulna is present after what age?
4. Tiue or False.Radiographic diagnosis of fragmented medial
coronoid process is usually made by detection of a well-defined
fracture line and a distinct separatecoronoid fragment.
5. A 4-month-old Great Dane has soft-tissueswellingaround the
carpi and tarsi, a high fever, and painful forelimbs. In radiographs,
there are lucent zonesin the metaphysesadjacent to the physeswith
sclerosisadjacent to the lucencies.Periostealnew bone formation is
present around the metaphyses.What is the most likely diagnosis?
6. Panosteitisis typically located in the:
A. diaphysis.
B. metaphysis.
C. epiphysis.
7. What general group of disorders often result in disproportion-
ate short-legged dwarfism ?
8. This elbow (Figure 13-21) is from an B-month-old German
shepherd dog with lamenessand pain isolated to the elbow region.
Describethe radiographicchanges.
9. These are forelimb radiographsof a S-month-old Irish wolf-
hound with an angular limb deformity (Figure t3-22). Describe
the radiographic findings.
10. This elbow is from a 6-month-old Labrador retriever with
Iamenessand pain in the elbow joint (Figure 13-23). What is the
radiographicdiagnosis?
Answers begin on page 727.
€z-gl en6!! zz-tL ern6!!

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ffi CHAPTER

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
taken at a 9O-degreeangle to each other (Fig. 1a-1). The joints
above and below the affected bone should be included in the field
of view; this allows for the assessmentof both joint involvement
and degreeof fragment rotation. The use of sedationor anesthesia
is helpful so that the animal may be positioned properly. A hori-
zontal-beam craniocaudal radiograph may be obtained when the
patient's condition, limb swelling, or decreasedrange of motion
prevents radiographing the limb in extension with a vertically
directedx-ray beam.' Stressed, oblique, and opposite-limbcompar-
ison radiographs are helpful in some patients.
I Gauses of fracture
An external force (usually trauma from an automobile accident,
horse kick, or gunshot) appiied directly to bone is the most com-
mon cause of fracture. An external force can be transmitted (indi-
rectly) through bone to another part of that bone where the
fracture then occurs. A dog that jumps off a porch and sustains a
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
the proximal ulnar epiphysis in a young dog is an example of this
type of fracture. Repeatedstressto normal bone over a period of
time (metacarpal fracture in a racing Greyhound) and normal
activity on diseasedbone (bone tumor or osteoporosis)can also
result in fracture.2
I Fracture recognition
Radiographically,a fracture is a disruption in bone continuity. One
or more radiolucent fracture lines may be seen,or there may be a
sclerotic line or zone where overlapping fragment ends summate.
Alterations in bone size,shape,position, and function are usually
presentto some degree.
Occasionally,a fracture is present, but bone distraction is mini-
mai, making radiographic detection difficult. Reasonsfor fracture
nonvisualization include poor-quality radiographs, a fracture line
not tangential to the x-ray beam, early cortical stress fracture,
minimal displacement, and obscured visualization by overlying
structures. Repeat radiographs, obtained with the use of proper
technique, or oblique projections may help. In some instances, a
more apparent fracture line or early callus formation will be appar-
ent in radiographstaken I or 2 weekslater (Fig. I4-2Aand.B).ln
instancessuch as early cortical stressfracture, nuclear scintigraphy
is indicated becauseof its inherent sensitivity in detecting bone le-
sions.
Occasionally,normal or variant anatomic structures may slmu-
late fracture. This situation occurs with normal or ectopic nutrient
foramina,3 normal and accessoryossification centers, inconstant
and multipartite sesamoidbones, open physes,and syndesmoses.
I Fracture evaluation
A radiographic assessmentbegins with a description of the direc-
tion and location of fracture line(s) in the bone(s) involved. The
use of a fracture type classification system to describe the fracture
is helpfu1 when appropriate.aThe direction of fissure fractures, the
presenceof joint involvement, and the presenceof intra-articular
fragments are carefully assessed.Intra-aiticular fragments may be
associatedwith luxation, subluxation, or any joint trauma. Next,
the positional changes of the major distal fragment relative to
the proximal fragment should be characterized. The direction of

Figure 1tl-|. Fracturedproximaltibial epiphysis.In the lat

e r a l v i e w , n o a b n o rm a lityis p r e se n t,b u t in th e cr a n io ca udal
vi e w , a f r a c t u r ec l e a r lye xists.lf a la te r a rl a d io g r a pahlo n eh ad
b e e n m a d e ,t h r s f r a ctu r ewo u ld h a ve g o n e u n d e te cte dT. h i s
e m p h a s i z etsh e i m p or ta n ce o f m a kin ga m in im u mo f two r a d i o-
g r a p h i cp r o j e c t i o nast r ig h ta n g le sto e a cho th e r .

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
evaluated. Alterations in bone length are described as overriding
(bone shortening) or distraction (bone lengthening). Rotational
deformities should be noted, although unstable distal fragments
that are fully movable vary markedly in rotational direction. Lastly,
the amount of soft-tissue change should be chatacterizedin terms
of size (i.e., swelling or atrophy) and opacity (e.g., emphysemaand
opaqueforeign objects).
Fracture type
Various fracture type classification schemeshave been devised that
describeintegrity of the regional soft tissues,geometry and number
of the fracture lines, degree of physeal-metaphyseal-epiphyseal
involvement, and the other pertinent features of a fracture. Most
fractures may be classifiedaccording to one or more types. Fracture
tfpe may influence therapeutic plan, rate of fracture healing, aP-
p.irance of fracture callus, and possibility of postoperativecompli-
cations. Most fractures may be classifiedaccording to one or more
of these category types.
1. Integrity of soft tissues:Skin defects in the region of a fracture
can communicate with the fracture site. This results in wound
contamination and can lead to bone infection if not treated
properly. Infected fractures may have delayed healing''
i. Open fractures have a skin defect in the region ofthe fracture.
Ridiographically, the bone may or may not protrude from
the skin. Occasionally, foreign debris, metallic opacities, or
tissue emphysema is identified deep within the soft tissue;
this finding servesas a clue that the fracture is open.
b. Closed fraclures do not have a skin defect in the region of
the fracture.
2. Descriptions of a fracture using geometry and number of frac-
ture lines:
a. Completefractures have a fracture line that extends through
the entire bone. The direction of the fracture line relative to
the long axis of the bone may be transverse,oblique, ot
spiral. Displacement of the distal fragment from the proximal
fragment due to muscle contracture is usually present.
b. Comminuted fractures have multiple fracture lines that com-
municate to a single plane or point. A triangular segment of
bone that may be present in a comminuted fracture is com-
monly referred to as a butterfly segment.
c. Multiple or segmental fractures are similar to comminuted
fractures in that there are three or more fragments, but the
fracture lines do not meet at a common point.
d. Incomplete fractures involve a single bone cortex or only a
portion of the bone. Several types of incomplete fractures
exist. Flssure fractures are longitudinal or spiral cracks in
the bone cortex without displacement. They are frequently
associatedwith complete or comminuted fractures (see Fig.
l4-2C).In greenstickfractures, which occur in young animals,
one side of the bone is fractured and the other side is bent
(plastic deformation). Stressfractures (fatigue fractures) are
microfractures in the bone cortex that result from cyclic
loading.u These are difficult to detect radiographically, al-
though increased uptake of a radiopharmaceutical may be
seen scintigraphically. Roentgen signs, when present, include
focal increased bone opacity, faint periosteai reaction, and
oblique to dish-shapedfracture lines that involve a single cor-
tex.
e. Impacted fractures result from compression forces that
shorten bone length by crushing bone. This results in a
sclerotic appearance. Impacted fractures occur most com-
monly in vertebral bodies or an open physis.
f. Depressionfractures are seen with sinuses or skull fractures.
A fragment of bone lies beneath the skull surface and a
radiolucent or sclerotic line is seen where fragment gap or
overlap occurs with neighboring bone.
g. Avulsion fractures usually occur as a result of excessivetrac-
tion by muscle, ligament, joint capsule,or tendon. Fragments
may be periarticular or intra-articular, or may involve trac-
tion epiphyses,which appear as fragments of variable size
with a defect or "fracture bed" in the parent bone the same
size as the fragment.
h. Chip fractures are small fragments that usually result from
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

L-J l\.J a distal extremity.

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

Figure 1th3. Sixtypesof Salterfractures. l, physeal;ll, physeal-metaphys- in regions of two bones with different growth
eal;lll, physealepiphyseal;
lV, physeal-epiphyseal-metaphyseal;
V, impacted
physis; physeal
Vl,eccentric impactionresultingin transphyseal bridging.
ment. A fracture bed is also present. Periarticular chips
should be distinguished from accessoryossificationcentersand
dystrophic soft-tissue mineralization The lack of a fracture
bed in the latter instancesis heloful.
i. Supracondylar,condylar,and bicindylar "7" and "Y" fractures
indicate that a fracture has occurred in the metaphysis near
the condyle, through the condyle, or through the condyie
and supracondylar region, respectively.
j. Fracture-Iuxations:Some luxations occur only in association
with a nearby fracture. This term is often reservedfor sacroil-
iac luxations becausesacroiliac displacement is almost always
accompanied by fracture of the pubis or ischium, or separa-
tion along the pelvic symphysis. A special tlpe of fracture-
luxation involves fracture of the oroximal ulna with cranial
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
rates, such as the
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
presenceof a physeal fracture.Io
4. Other features: Pathologic fractures are spontaneous fractures
that occur without history of overt trauma in abnormal bone
weakenedby a pre-existing lesion. Pathologic fractures are most
often seen in bones that are weakenedby tumor. An aggressive
bone lesion in conjunction with a fracture is indicative (Fig.
14-6). Metabolic bone disease,especially hyperparathlroidism,
as a cause of pathoiogic fracture is suspect when a fracture
occurs in bone that is radiographically less opaque than normal
with thin cortices and scant trabeculae.ThesesometimesDresent
asfolding fractures when the bony cortex is bent at the fracture
site, thereby creating a sclerotic fracture line. Also, in folding
fractures, there is no fragment distraction (Fig. 14-7).

:;
:,4::,

Figure 744. Craniocaudal (A) and lateral1B)view of a

d i s t a lu l n a rm e t a o h v se afrl a ctu r ea n d a d ista lr a d iaSa
l lte r
ll p h y s e aflr a c t u r eM. i n im a d l isp la ce m e notf th e e p ip h ysis
makes detecting the physeal fraclure (arrows) difiicuft.
I6 4 R EL E T O N -C A N INAEN D FE LIN E
A P P E NDI CU L ASK

Figure 14-5. Lareal (A) and craniocaudal /B)

radi ographs of an i mmaturedog 2 monthsfol l ow -
i ng a fractureof the di stalradi usand ul na.P rema-
ture cl osureof the di stalul narohvsishas res ul ted
in a valgus and rotationaldeformity of the fore-
l i mb.Therei s proxi malsubl uxati on o f the humer-
oul narj oi nt w i th remodel i ngof the anc onealpro-
cess and semiLunarnotch of the ulna. Lateral(C)
and craniocaudal/D radiographsof the elbow of
a young dog w i th i nsuffi ci entl ong i tudi nal
radi al
growth. Note the distal subluxationof the radlus
and proxi malsubl uxati on of the ul nafrom the hu-
merus.

Figure ltl-6, Lateralradiographin which an expansilelesion of the distal
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
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.
Periostealbone is presentadjacentto the fracture.Histologicdiagnosis:fibro-
sarcoma.
Figure 14-7, Pathologicfracture of the proximalfemur from secondary
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
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
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.
FractureH eal i ngand C omp licat ions165
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-
lus that is replaced by bone. This is the most frequently encoun-
tered form of bone healing. The cells participating in the healing
processare pluripotential mesenchymalelements,which differenti-
Figure ltI-8. Twelve-weekfollow-upradiographof a healedproximalradial
fracture.The fracturel i ne i s no l ongerevi dent,and there i s c onti nui tyof the
cortexand medullarvcavity.Anatomicreductionand stablefixationresultedin
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
healing
5-10 days post-reduction
Fracturefragments lose sharp margins
Demineralization of fracturefragment ends resultsin slight
fractureline widening
10-20 days post-reduction
Formationof endostealand periostealcallus
Decreasingsize of fracturegaP
Variableloss in opacity of free fracturefragments
After 30 days post-reduction
Fracturelines graduallydisappear
Externalcallus increasesin opacity and remodels
After 3 months post-reduction
Continuedremodelingof externalcalluses
Trabecularpattern may develop within the callus
Corticalshadow becomesvisible through the callus
MeduIlary cavity continuity re-established g radually
Corticalremodelingalong the lines of stress
ate into osteoblasts,fibroblasts, or chondroblasts,depending on the
soecificmicroenvironment at the time. A local cascadeof molecular
mediators of inflammation, as well as angiogenic factors, growth
factors, and electroconductivity potentials, also play an important
role in the healing process. Bone cannot form in an unfavorable
environment (motion). Therefore, under conditions of instability'
the mesenchymal cells of the periosteum respond by producing a
fibrous to fibrocartilaginous callus. With time, this callus bridges
the fragments and increasesstability. The stable environment per-
mits vascularization of the callus, resulting in callus ossification
Figure 1/r-9. Sequentiallateralradiographs fracturethat healedby secondarybone healing,A, In the initialpostreductionradiograph
of a midshaftantebrachial
there is approximately50% purchaseof the fracturefragments.A cast has been placedon the limb. Pins were used with a reductionapparatus,causingthe pin
tracts in the rcdius(arrows).B, Poorlymineralizedimmaturecallus{2-weekfollow-up).C Mature callusbeginsto bridgethe fracture{4-weekfollow-up).D, Healed
f racture(1O-weekfollow-up).
and thus bony union. Callus size is determined by a host of factors:
fiacture type, degree of stability, width of the fracture gap, and
vascularity of the regional soft tissues.
The following radiographic description of uncomplicated sec-
ondary bone healing is of a simple long-bone diaphyseal fracture
that has been stabilized with an intramedullarv oin (Table 14-1).14
By the first week,fragment ends begin to lose'their sharp margins,
and the fracture gap increases slightly in width. These changes
result from a combination of interfragmentary motion, resorption
of necrotic bone ends, and vascular ingrowth. Within the next 2
weeks, variable amounts of periosteal, endosteal, and intercortical
callus appear.Initial periosteal callus is faintly mineralized and has
irregular margins; it is located subjacent to the cortex on each
fragment a slight distance from the fracture gap. By 4 weeks, the
callus is smoother and more opaque and is visualized as a cuff of
bone beginning to bridge the fiacture gap; the fracture line should
be smaller in size. After 4 weeks, the fracture line is slowly obliter-
ated and the bony callus bridges the fracture area. At this point,
the callus should be as opaque as normal bone. After 12 weeks,
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).
Clinical unron. Clinical union refers to that ooint in fracture
healing when the fixation or stabilization device can be removed,
and the animal returned to some degree of normal activity. A
combination of radiographic, clinical, and historical evidence is
used in making this assessment.Knowledge of the factors that
modif' fracture healing is important in this regard.
Factors that modify fracture healing
In the evaluation of fracture healing, many factors that influence
healing or contribute to complications must be considered.Under-

'standing their role partially explains the radiographic appearance
of follow-up evaluations.
Vascular integrity. The normal blood supply of a long bone is
derived from several sources (Fig. 1a-10). Although the degree
of vascular compromise to a fractured bone is not detectable
radiographically, vascular disruption can be estimated based on the
tlpe and location of the fracture and the degree of separation and
overriding of the fragments(Fig. 14-11).
Normal vascular ingrowth at the fracture site occurs within the
first 10 days after injury. Radiographically,this ingrowth is seen as
slight demineralization of fragment ends that results in slight wid-
ening of the fracture gap and finzy fragment margins. Isolated
bone fragments that are revascularizingrespond similarly. Regional
vascular status also influences callus characteristicsbecauseof the
effects of relative tissue hypoxia on stem cell differentiation.ts A
rich vascular network results in pluripotential daughter cells that
become osteoblasts.Decreased vascularity below a critical point
results in chondroblasts or fibroblasts. The produced bone or
fibrocartilage differs in radiographic opacity. Becauseof compro-
mised circulation, the initial callus formation at the fracture site is
fibrocartilaginous (soft-tissue opacity). Initial mineralized callus
forms at a slight distance from the fracture gap where the circula-
tion is less compromised. With increasing stability and subsequent
vascular ingrowth, the entire callus mineralizes.
The temporal sequenceof revascularization after a fracture and
the associatedroentgen findings vary for each fracture. This varia-
tion is the result of differencesin the extent of the initial circulatory
compromise, postreduction fragment stability, and the available
soft tissue in the region, which is a principal source of neovascular-
Figure 14-1O. The blood supply to long bones is derived from several
so u r c e s .T h i s d i a g ra md e p ictsa lo n g b o n e with a n o p e n physi s.Fol l ow i ng
p h y s e a lc l o s u r e ,v a scu la rtu fts o f th e e p ip h yse aal n d m e t aphyseal
arteri es
u n i t e .a . , a r t e r y .
FractureH eal i ngand C omp licat ions167
Figure 14-11. Severe comminutionandfragment displacement in thisfem-
oralfractureprobably
resultedin damage
to the nutrientarteryandperiosteal
bloodsupply.
ization for healing bone (extraosseousblood supply of healing
bone).tu
Fracture location. The anatomic location of a fracture may
influence the healing response.For example, metaphysealfractures
have an early onset of mineralized callus when compared with
diaphyseal fractures; this is due to the rich blood supply in the
metaphyseal region and to the abundant trabecular bone with its
increasedsurface area. In general, metaphysealfractures heal more
rapidly than diaphysealfractures. Antebrachial diaphysealfractures
in miniature breeds and tibial shaft fractures in mature dogs heal
more slowly and have a greater incidence of complication than do
other diaphyseal fractures because there is decreased soft-tissue
support and poor vascularsupply in the region.17,tt Healing capital
femoral physealfractures and femoral neck fractures undergo rapid
revascularization if they are adequately reduced and stabilized. In
some instances, an exuberant fibrovascular response may occur,
which causeslocal osteoiysis of the femoral neck.'e Radiographi-
cally, this responseresults in femoral neck narrowing, which may
proceed to an "apple core" appearance(Fig. 14-12). Narrowing of
the femoral neck may occur in as many as 70o/oof the healing
capital physeal repairs. In most dogs, this narrowing is not associ-
ated with complications.'?o
Degree of motion. Stability and adequate blood supply are
related factors that are essential for normai fracture healing. An
unstable fracture results in damage to the microvasculature in the
region. Radiographically,fracture fragments may retain their sharp
margins longer than usual. Initial callus at the fracture site is
usually poorly mineralized and nonbridging (Fig. 14-13). Periosteal
stimulation due to fragment motion may result in callus formation
at a point distant from the fracture site. The callus initially presents
as ill-defined, poorly marginated periosteai new bone that extends
over a large portion of the diaphysis. This later finding, however,
is not specific for fragment motion; it may occur secondary to
periosteal stripping at the time of injury or surgery or to early
osteomyelitis. Clinical signs may help in this distinction.
Persistent motion results in exuberant fibrocartilaginous callus
formation, which is an attempt by the body to provide stabiliry. If
the callus later mineralizes, it usually does not bridge the fracture
gap. Intramedullary pin migration may also be present (Fig. 1a-
I6 8 A P P E NDI CU L AR E D FE LIN E
S KE L ET ON -C A N INAN

Figure ltl-|2- Follow-upradiographof a capitalfemoralphysealfracture1 month after

repair.Note the considerablebone resorptionin the femoralneck.An exuberantfibrovas-
produci ngan "appl ecore " appearanc e
cul arheal i ngresponseresul tedi n l ocalosteol ysi s,
of the femoralneck.

t:):a::'!))l:.

Figure 14-13. Lateralradiographof a comminuted femoral fracture 3 weeks after

suigery.The surgicaldevices have not maintainedstability,and the main fracture frag-
ments are telescoping.There is a mineralizedperiostealreactionin the soft tissue that is
the fracturefragmentsare sharplymargin-
typicalof strippedperiosteum.Radiographically,
ated, suggestingnonhealingdue to poor regionalmicrovasculature.
 FractureH eal i ngand C omplicat ions169

14). If motion is severe,complications such as delayedunion or

nonunion may result.
Adequate stabiiization and vascular integrity lead to the early
formation of a well-mineralized callus. The callus is small to mod-
erate in size, sharply marginated, and limited to the fracture site.
Rigid fixation with an external fixator or plate results in minimal
to no callusformation (seeFig. 14-8). Radiographicassessment of
fracture healing in this instance may be difficult. In this situation,
one may have to rely more heavily on clinicai assessment.
Fracture type and degree of postreduction apposition. The
type of fracture, the degreeof initial displacement,and the accrracy
of reduction influence fracture-healing characteristics.Spiral and
long, oblique diaphyseal fractures heal with more callus than do
transverse fractures. Comminuted fractures with multiple frag-
ments may heal more siowly and with more variable callus than
do simple fractures. Gunshot fractures with severesoft-tissueinjury
are often associatedwith delayed union (Fig. l4-15).2t Open frac-
tures have a greater tendency for osteomyelitis and complications
than do closed fractures.
Severedisplacement of fragments with marked overriding indi-
cates severedisruption of the periosteum and regional vasculature.
Periosteal stripping alone may stimulate the production of new
bone. In these instances,the extent of the periosteal reaction often
exceedsthe anatomic limit of the fracture itself. Damaged regional
vasculature regenerateswith time as stability improves.
Poor postreduction apposition may adversely affect stability and
thus callus characteristics and healing time. Large fracture gaps
require more callus and time to bridge the fragments. Good reduc-
tion and alignment minimize the callus requirement and promote
anatomic restoration. Good alignment is also important for proper
joint function and helps prevent fracture diseaseand osteoarthrosis. Figure ltI-I5. Lateralradiograph of a severelycomminuted gunshot-in-
ducedfractureof the humerus. Multiplemetallicfraoments are identified
withinthe softtissues.Gunshot fracturesareopenfractu-res
thatusuallycause
extensive regional soft-tissue
traumaowingto the projectile. Bothof these
factorscontribute to complications in the healingprocess.
Thisfracturewas
stabilized
by usinganexternal fixatorandeventually healed1 yearlater.

Cancellous bone grafts to augment fracture healing may result in

visible islands of ill-defined soft-tissue mineralization at the frac-
ture site.As time progresses, thesemineralized areasbecome more
uniform in opacity and begin to incorporate fracture fragments.
Age. Juvenile bone heals more rapidly (2 to 4 weeks) and with
more exuberant callus formation than mature bone. This is because
the immature skeleton is rapidly growing and has a more extensive
blood supply than the adult skeleton.Young animals also exhibit a
periosteal reaction after injury that is especially evident at sites
where hear,yfascialattachments are stripped from bone, such as the
adductor muscle attachment to the caudal femur. In this instance,a
prominent spike of new bone formation coursing proximally in
the caudal musculature may occur. This finding is seento a variable
degree in all dogs but seems to be more prominent in younger
animals (Fig. la-l6).

I Postreduction and follow-up

Figurc 1/t-14. Follow-uplateralradiographof a Y{ype distal humeralfrac-
t u r e 2 m o n t h sa f t e r r e p a irT. h e r eis m ig r a tio no f a a r g e in tr amedul l ary pi n i n a
p r o x i m adl i r e c t i o nA. n e xu b e r a nnt o n b r id g inpge r io ste aaln d e ndosteal cal l usi s
v i s u a l i z e dT.h e s ec h an g e ssu g g e stin sta b ility a t th e fr a ctu r esi te and i nfecti on.
I radiographic evaluation
Initial postoperative evaluation
The immediate postoperative radiographs should be evaluated for
the quality of fracture reduction, fragment apposition, fragment
alignment, and proper placement of fixation devices. The degree
of fracture reduction refers to the number of fraement ends that
are in contact with each other. For simple fractuies. 50yo contact
is the acceptableminimum for adequate healing, but more is
desirable. foint fractures require more accurate reduction for ade-
quate function. Joint incongruities are identified as "step" deformi-
ties or fracture gapsthat disrupt articular contour (Fig. 14-17).
I7 O R EL E T O N -C A N INAEN D FE LIN E
A P P E NDI CU L ASK

abduction or torsion of the distal limb by the holder during

radiography may simulate rotational or angular malalignment of
the distal fragment in the postoperative radiograph. In addition,
changesin the angle of the x-ray beam relative to the fracture may
project fragments differently. These artifacts may be avoided if the
animal is carefully positioned.
Next, the orthopedic fixation device is evaluated for placement
and for its ability to maintain reduction and prevent motion
throughout the healing phase. Weaknessin fixation placement, if
caught early, may be corrected, and disastrous complications may
be avoided. Intramedullary pins should be seateddeeply and should
span the fracture gap adequately.The pins should be of sufficient
size for the bone involved and should not penetrate the joint. The
far and near pins of a two-pin external fixator apparatus should be
properly angled toward the bone, just penetrating both cortices.
Wires should be of adequate size, they should not be kinked or
broken, and each arm should be twisted equally. The wire should
be seated snugly against the cortex with a minimum of space
between it and the bone. Bone plate size is important to evaluate.
Excessiveiylarge plates may result in stressprotection of the bone
and bone atrophy-demineralization. Implants that are too small
may result in instability at the fracture site, with delayed union or
nonunion as a possible sequel. Bone plates should be anchored
securely to the bone, with a minimum of six cortices engagedby
the bone screwsabove and below the fractures. Bone screwsshouid
be solidly seatedand fully engagedin each cortex. The orthopedic
devices should not cause fragment distraction or be interposed
between major fragments.

Figure 14-16. Lateralradiograph of a pinnedfemoralfracture.Thereis
in the areaof attachment
mineralization muscle(solidarrow)
of the adductor
Maturecallusis presentat the fracturesite(openarrow).
Fragment alignment and rotation should aiso be assessed.Exact
anatomic alignment is desirable but impossible to accomplish in
all fractures for al1 fragments. Rotation of the distal fragment
relative to the proximal fragment is an important finding that may
have serious consequencesif not identified and corrected. The
accurate assessmentof alignment and rotational deformities, how-
ever, requires the use of good radiographic positioning. Excess
Follow-up evaluations
The limb should be remeasured during each radiographic evalua-
tion, and appropriate kilovoltage peak (kVp) and milliamperage
(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-
nificantly during fracture-healing evaluations Follow-up studies in
which the same exDosurefactors were used as for the initial fracture
radiograph markedly in tissue opacity.
Bandages,-uyl'nty
casts,and external fixation rods should be removed if
possible before radiography. A clear, unobstructed view of the
fracture area is then ensured. If cast removal is impractical, the
following technical alterationsare suggested.For plaster casts,

Figu r e l 4 - 1 7 . bi alfracture.A smalfracturegapoftheti

A , l m m e d ia te p o str e d u ctio n r a d io g r a p h o fa proxitimal l bi alarti cul arsurfacei spresenl (arrow ).Thei oi nt
s urf a c e i s S t i ] | c o n g r U en t;th e r e fo r e ,th isiSa cce p ta b | e r e d u cti on.B .Fo|ow -upradl ographS hoWi nga,,stepdeformi ty,,oftheproxi mal t i bi a|arti c U 1ar
The in c o n g r u i tw jo in td ise a se .
y i l l e a d to d e g e n e r a tive
 FractureH eal i ngand C omp licat ionsl7l

'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.

Radiograph evaluation scheme

To ensure that vital information is not overlooked, the ABCDS
mnemonic system may be used for evaluation of postreduction
films. The five letters in the mnemonic stand for Alignment, Bone,
Cartilage (joints), Device (orthopedic appliance or device), and
Soft tissues. When this system is used, a complete radiographic
evaluation is ensured.
Alignment. The major and minor fracture fragments should be
evaluated for any changes in alignment, reduction, or rotation
since the previous study. This evaluation is especially important
for poorly reduced fractures or for those stabilized with intramed-
ullary pins in which rotational forces are not adequatelycontrolled.
Bone. The bone should be evaluated for the prosression of
fracture healing and callus formation. All fragments should be
involved in the healing responseand should be in the samelocation
as in previous radiographs. Fragments that are poorly vascularized
retain their sharp margins radiographically. With time, they may
revascularizeand become incorporated into the healing processor
they may become ischemic and develop into a sequestrum. Persis-
tence of sharp margins and an increased opacity of the fragment
on subsequentradiographs indicate sequestrum formation.
Fragments removed surgically create defectsin the region of the
fracture. Large defects seldom fill in completely and may serve as
a point of stress concentration, rendering the implant vulnerable
to bending or brefing. The bone may also be weaker at this site
when the implant is removed.
The overali bone opacity and architecture should also be evalu-
ated. Complications such as osteomyelitis and disuse atrophy, if
gone unsuspected, may be well advanced by the next follow-up
examination. The routine evaluation of bone ooacitv and architec-
ture may help identify suspect areas and, thus, appropriate treat-
ment planning.
Excessiveperiosteal reactions are often seen either at or distant
from the fracture site. These reactions may result from a number
of possibilities: normal callus for that fracture, rotational instability,
infection, and periosteal avulsion or stripping at the time of injury
or surgery (Fig. i4-18; seealso Fig. 1a-16). On follow-up studies,
many plated bones have a variabiy sized callus. This finding may
suggest some instability, but other possibilities inciude interfrag-
mentary callus formation due to the size of the fracture gap,
cancellousgrafting with new bone production, and periosteal
trauma during surgery.
Situations in which no to minimal callus formation is evident
are occasionallyencountered. Possibilitiesfor such scant formation
include too short an interval since fixation, primary bone healing
Figure ltl-l8. Craniocaudal radiograph 4 weeksafterinternal fixationof a
midshafttibialfracture.
Thereis a smoothly marginated, continuous periosteal
reactionsurroundingthe fragmentsdistalto the fracturesite.Periosteal
strip-
pingat thetimeof injuryandslightrotational instability
couldaccount for the
finding.
Thesmoothmargins suggestchronicity. Whenthe fracture sitewas
examined 2 weekslater,therewascomplete fragmentunionandthe orthope-
dicdevices wereremoved.
(must have anatomic reduction and rigid fixation), rigid fixation
resulting in minimal callus formation, compromised vascularity
with poorly mineralized callus, and atrophic nonunion. Clinical
signs, history, and serial radiographs are helpful in distinguishing
among these possibilities.
Cartilage. It is important that the joint spacesnear the fracture
be evaluated. For articular fractures, the apposition of fragments
should be carefully evaluatedon standard and oblique views. foints
should be scrutinized for evidence of migration of the orthopedic
device into the joint space.The development of joint effusion, an
irregular periosteal reaction, and subchondral bone lysis may signal
septic arthritis. ]oint effusion in the presence of osteophytes is
suggestiveof degenerativejoint disease.The range of motion of
the joint is better evaluated clinically than radiographically.
Orthopedic device. The placement and position of the ortho-
pedic implants should be compared with those on previous radio-
graphs. Always check for movement, bending, or breakageof pins,
wires, plates, and screws. Minimal implant bending may be de-
tected by placing a straight edgeon the radiograph. A ioose implant
is painful and does not provide the structural support for which it
was intended. A radiolucency is often noted in bone at the point
where a metallic device is located (Fig. 1a-19). The list of radio-
graphic diagnosesto be ruled out for this finding includes motion
of the implant or fracture fragments, bone necrosis secondary to
high-speed drills, metallosis,'3and osteomyelitis.Radiolucent spaces
around a metal implant that are uniform in width and end with
visible sclerotic margins suggest bone resorption from noninfec-
tious causes;those with uneven zones of resorption and indistinct
margins are iikely infected.'zaBone loss around an implant may be
sufficient to result in loosening, but not in detectable radiopacin'
changes,because50o/oof bone matrix must be lost before a lrtic
area is detectableradiographically.
I7 2 A P P E NDI C U L AR E D FE LIN E
SK EL E T O N -C A N INAN

The appropriate time for removal of a surgical implant (clinical

union) varies with each patient and should depend on a blend of
clinical and radiographic information, but mostly on good clinical
judgment. Clinically, the limb should be palpably firm and non-
painful, and some weight bearing should occur. Radiographically,
pin implants are removed if the fracture line is not visible and
normal callus bridges all or most of the fracture. Removal of plate
implants follows similar principles, although callus is more vari-
able, depending on the type and severity of the fracture and the
rigidity of fixation. Suggestedtimetables for plate removai have
been published.2s'26 In one study, 3 to 5 months for young animals
and 5 to 14 months for adults were the recommended intervals.2T
Removal of screws and pins penetrating the cortex leaves defects
in the bone. Although these areasfill with bone, the new bone is
less opaque, and thus the defect may remain radiographically ap-
parent for months to years.27If an implant is removed prematurely
or physical activity is too vigorous shortly after removal, refracture
through the original fracture site may occur.
Soft tissues. Postoperativeemphysema and soft-tissue swelling
are usually gone or are significantly decreasedwithin 7 to 10 days.
Subcutaneousand fascial emphysema is recognized as rounded or
linear air opacities within the soft tissues. Soft-tissue swelling is
characterizedby the loss of fascial plane visualization and increased
limb size. Air pockets with soft-tissue swelling that recurs after
initial subsidenceindicate infection. Chronically, soft-tissue atrophy
results in loss of fascial plane visualization with a decrease in
muscie mass. Calcification of soft tissuesin animals with a fracture
is occasionally seen,possibly resulting from an isolated bone frag-
ment or cancellous grafts within the soft tissue, dystrophic min-
eralization, mineralization of hematoma, and myositis ossificans.
Soft-tissue mineralization may also occur in conjunction with an
aggressivebone lesion secondaryto osteomyelitisor fracture-associ- Figure 14-2O. Lateralantebrachial
radiograph
in whicha malunited
fracture
of thedistalradius
andulnais aooarent.
ated sarcoma.

I Fracture complications change in the sharpness of fragment margins. Fragment motion

Malunion is defined as bone healing in an abnormal position (Fig.
14-20). If deformity is severe,functional impairment may ensue,
or abnormal weight bearing may result in joint arthrosis. When
malunion occurs within a joint, the incongruiry leads to degenera-
tive changes.
Delayed union is present when a fracture has not healed in the
time expectedfor the bone involved and the type of fracture (Table
14-2). Radiographically,fracture lines remain evident with minimal
callus bridging the fracture gap. In addition, there may be minimal
Figure 14-19. There is an obviousradiolucenttract surroundingthis trans-
t r e su l ti n l ooseni ng
v erseK i r s c h n eori n .T h i sa m o u n to f b o n elo ssis su fficie nto
the implant.The even bone resorptionand sharp demarcationto normalbone
arou n dt h i s p i n t r a c ts u g g e stsa n o n in fe ctio uca
s u se .
due to instability is the most common cause of delayed union. If
the underlying cause is adequatelycorrected, healing will ensue. If
the situation is not remedied,nonunion may result (Fig. 14-21).
Nonunion is the situation in which all evidence of fracture
healing has ceasedand the fragment ends have not united. Sequen-
tial radiographs are helpful in making this assessment.Radiograph-
ically, nonunion has been classified as hypertrophic and atrophic
(Fig. ru-22). Clinically, it may be important to distinguish between
the two.'z8Hlpertrophic nonunion has a well-defined fracture gap,
a small to large (elephant foot) nonbridging callus, sclerotic frac-
ture ends with a closed marrow cavity, and fragment ends that are
smooth, rounded, and well defined. Atrophic nonunion has mini-
mal if any callus formation, a well-defin"d ftu.tn.e gap, and sharply
marginated to tapered fragment ends with a sclerotic marrow
cavity. Demineralization of bone and soft-tissue atrophy may be
present in each instance in varying degrees.
In some nonunion fractures, a pseudoarthrosis (false joint) may
form. Bone ends are connected by a fibrous tissue structure resem-
bling a joint capsule that contains mucinous sprovium-like fluid.
Radiographically,presumptive evidence of a joint may be seenas a
soft-tissue mass at the fracture site with focal bone fragments
appearing in a flexed position.
Osteomyelitis as a complication of bone healing is usually due
to a combination of local contamination with bacteria, local avas-
cular bone, and instabiiity (Fig. M-23). Potential causes include
contamination from open fractures, long surgical procedures with
wide exposure, excessivetissue damage from the trauma or during
surgery, and contact with foreign objects (sequestra,sutures and
sponges,and occasionally,the implant itself) (seeFig. 14-23).The
diagnosis of osteomyelitis at a fracture site is usually suspected
clinically before the radiographic changes are positive. Clinical
signs of acute osteomyelitis include fever, local heat, swelling, and
 FractureH eal i ngand C omplicat ions173

Table 14-2, Approximate time to reach clinical union in a noncomplicated

diaphyseal fracture
External Skeletal and
IntramedullaryPin
Age of Animal Fixation Fixation with Plates
Under 3 m o 2-3 wk 4wk
3-6 mo 4-6 wk 2-3 mo
6- 12 m o 5-8 wk 3-4 mo
Over 1 yr 7-12 wk 5-8 mo

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
may be the only abnormality seen on initial radiographs. In repeat
radiographs 7 to 10 days after the onset of clinical signs, a general-
ized, irregular periosteal reaction is a common finding. As the bone
infection progresses,radiographic signs of an aggressivebone lesion
may develop (see Fig. 14-23). A combination of corticomedullary
osteosclerosiswith areas of osteolysis surrounding pin metallic
implants is highly suggestiveof motion or pin tract osteomyelitis.
Pin tract osteomyelitis is frequently associatedwith external fixator
pins (seeFig. 1a-19). Irregular periostealreactionsare often noted
at the pin-cortex junction.
A sequestrum is a dead bone fragment. It may be parosteal,
cortical, or intramedullary in location. Classically,an infected se-
questrum is recognized as a sharply marginated sclerotic fragment
separatedfrom the parent bone by a zone of radiolucency and an
outer rim of sclerotic bone (involucrum) (Fig. 14-24). In some
instances,the draining tract is evident (cloaca). Bone sequestra
may be associatedwith infections or draining tracts. Failure of any
isolated bone segment to be resorbed or revascularizedmay result
in sterile sequestra.In these instances,the reaction of surrounding
bone tissue is less exuberant, and clinical signs of osteomyelitis are
not present.
Nerve injury may be associatedwith the initial fracture (e.g., the
radial nerve in spiral humeral fractures) or with fracture repair
and healing (e.g., the sciatic nerve in femoral fracture pinning).
Fracture-related sciatic palsy may occur with medially displaced
caudal ileal shaft fractures or sacroiliac fracture-luxation with cra-
nial displacement of the ilium.,e It may also occur secondary to
surgically induced trauma, scar formation in the region of the
nerve, and the proximal placement of the pin in the femur.3oThe
more medial the exit of the pin is relative to the greater trochanter
and the longer the exposedproximal portion of the pin, the more
likely is the occurrence of sciatic entrapment (Fig. 14-25). Thus,
postoperative femoral radiographs should be evaluated for proxi-
ma[ pin location.
Bone atrophy-demineralization may result from chronic disuse
of the limb or from stressprotection by the orthopedic device. A
generalized decrease in bone opacity with coarse trabeculation
involving the entire limb signifies disuse atrophy-demineralization.
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

Figure 1*22. ,4, Hypertrophicnonunion.In thts lateral

view of a chronicdrstalhumeralfracture,there is a well-
defi nedfracturegap,a nonbri dgi ng cal l usformati on,and a
scl eroti c marrow cavi ty of the fragment ends . B , A n
atrophi cnonuni oni s evi denti n a 3-monthfo l l ow -upradi o-
graphof a proxl malti bi alfracture.N ote the fragmentdi s -
tracti onw i th a w el l defi nedfracturegap, no v i s i bl ec al l us
formati on,sharpl ymargi nated fragmentend s , and a s c l e-
rotc marrow cavrTy.

Figure 14-23. A, Lateral view 4 weeks

ait er r e p a i ro f a p r o x i ma lfe m o r a l fr a ctu r e .
There is abundantperiostealreaction,cortical
t hinn i n ga, n d p e r m e a t i v oste e o lysiso f th e d is-
t al f e m o r a lf r a g m e n t T . h e r eis m in im a lca llu s
formation associatedwith the fracture site.
Rad i o g r a p hdl ci a g n o s i so: ste o m ye litis. B, L a t-
eral view of a previousproximalfemoralfrac-
t ure i n w h i c h a s p o n g ewa s le ft p o sto p e r a -
t iv el y .T h e r e i s b o n e d l sco n tin u ity,co r lica l
des t' u c to n , i l l - d e f . n epder io ste a' el a ctio r ,a n d
s of t - t i s s u m th ;e sesig n ssu g g e st
e i n e r a l i z a t i on
os t e o m y e l i t i A m in e r a liza tio
s .s h e l l - l i ke dne ve l-
oped aroundthe sponge larod.
 FractureH eal i ngand C omplicat ions175

'rriii
dll: ,rllrrrr

Figure 1/t-24. Chronicmidshaftfemoralfracture had an associateddrainingtract for several

months.Two wellmarginatedradiopaquecorticalfragments(sequestra) were identified(solidand
open arrows).The largestfragment (openarrow)is sunoundedby a zone of radiolucencv and an
o u t e rr i m o f s c l e r o t icb o n e ( in vo lu cr u m ) .

tlt,:rllll,tr,
,,1

t:11@utt:i1131
ltlll3ll,,.rrrr,
iil@u:1i119U:
-'a -l
"*eS

Figure 14-25. Craniocaudal radiographof a midfemoralfracture immediatelvafter reoairwith three full-

ce r cla g ewi res and a l argei ntramedul l arypi n. Therei s a more medi alexi t of the oroxi maol i n rel ati v eto the
g r e a te rtr ochanterthan desi red.A ddi ti onal l y,
a l ong,exposedproxi malporti onof the pi n i s ev i dent.B oth of
th e se fa ct orscontri buteto a reactveti ssue scar that coul d entrapthe sci ati cnerve.The therapeuti cpl an
in clu d e scutti ngthe pi n to decreasei ts ength.
176 R EL E T O N -C A N INAEN D FE LIN E
A P P E NDI CU L ASK

within 2 or 3 weeks in very young animals but takes longer in the

adult. Focal decreasesin bone opacity and cortical thickness subja-
cent to an orthopedic implant suggest demineralization due to
stress protection by the implant. Stress protection is related to
increasedimplant size and stiffness and not to implant tlpe (plate
or pin) (Fig. 1l-26). In this instance, sequential removal of im-
plants or parts of implants will result in increasedbone stressand
mineral deposition, which may be monitored radiographically.
Joint complications after fractures include degenerative joint
disease,ankylosis,and soft-tissuemuscular and capsular con-
tracture. Physeal growth deformities may follow direct trauma to
the physis or may result from radioulnar synostosis(seeFig. 14-5).
Fracture-associatedsarcomas in the dog have been described.3l
The causeis unknown, but theories include coincidental spontane-
ous osteosarcomas,carcinogenesisdue to corrosion byproducts
of metallic implants, and the co-carcinogenic effects of chronic
inflammation in an environment in which stem cells are proliferat-
ing (fracture healing). Current evidence suggeststhat the last is the
most likely cause. The overall incidence is low and a variable
postfracture latency period is usually present (mean, 5.8 years). The
femoral diaphysis is the most frequently involved site of fracture-
associatedsarcoma (Fig. Ia-27). The roentgen signs are those of
an aggressivebone lesion with soft-tissue mineralization, which
occurs in the location of a previous fracture that had experienced
serious postoperative complications, such as infection, delayed

Figure 1tl-27. A, Lateralview of a midshafttibialfracturerepairusinga

boneplate.8, Samelimb5 yearslater. Thereis a midshaft aggressive bone
periosteal
lesionwth extensive reactionandsoft-tlssue Histo-
mineralization.
logicdiagnosis:
undifferentiated
sarcoma.

union, implant loosening, and draining tracts.32A draining fistula

may be present in some instances;thus osteomyelitis may be pres-
ent simultaneously. The lungs should always be examined radio-
graphically for potential metastatic diseasewhen limb neoplasia is
suspected.

References

1. Beck K: Caudocranial horizontal beam radiographic projection for evaluation of

femoral liacture and osteotomy repair in dogs and cats. I Am Vet Med Assoc
198:1751,1991.

2. Carter D, Spengler D: Biomechanics of fractures. In Sumner-Smith G (ed): Bone

in Clinical Orthopedics. Philadelphia, WB Saunders, 1982.

3. Orsini PG, Rendano Vl SackWO: Ectopic nutrient foramina in the third metatar-
sal bone ofthe horse. Equine Vet J 13;132,1981.

4. Pitt M, Speer D: Radiologic reporting oforthopedic trauma. Med Radiogr Photogr

15:14, 1982.

5. Dernell W: Treatment of severe orthopedic infections. Vet Clin North Am Small

Anim Pract 29:126I. 1999.

6. Carter D, Spengler D: Biomechanics of fracture. In Sumner-Smith G (ed): Bone

in Clinical Orthopedics. Philadelphia, WB Saunders, 1982.

Figurc 1/r-26, A, Lateralview of the antebrachiumof a 2-year-olddog 1
year after correctiveosteotomy for radiuscurvus. The dog was moderately
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
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
focal area of decreasedbone opacity involvesthe radius beneaththe bone
plate and two innermostscrews (arrow).These findingsare compatiblewith
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
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
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.
7. Salter RB, Harris WR: Injuries involving the epiphyseal plate. J Bone Joint Surg
451587,1963.
8. Llewellyn HR: Growth plate injuries: Diagnosis, prognosis and treatment. ] Am
Anim Hosp Assoc12:77,1976.
9. Marretta SM, Schrader SC: Physeal injuries in the dog: A review of 135 cases.l
Am Vet Med Assoc 182:708,1983.
10. O'Brien TR, Morgan J, Suter P: Epiphyseal plate iniury in the dog: A radiographic
study of growth disturbance in the forelimb. J Small Anim Pract l2:I9,1971.
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
Treatment and Healing. Philadelphia, WB Saunders, 1980.
19. Hulse DH, Abdelbaki YZ, Wilson l: Revascularization of femoral capital physeal
fractures following surgical flration. J Vet Orthop 2:50, 1981.
20. DeCamp CE, Probst CW, Thomas MW: Internal fixation of femoral capital physeal
injury in dogs: 40 cases(1979-1987).I Am Vet Med Assoc 194:1750,1989.
21. Swan KG, Swan RC: Gunshot Wounds: Pathophysiology and Management. Little-
ton, MA, PSG Publishing,1980.
22. Morgan lP: Radiographic diagnosis of fractures and liacture repair in the dog.
Small Anim Vet Med Update Series19:1, 1978.
23. Saffar N, Revell PA: Interleukin-l production by activated macrophages sur-
rounding loosened orthopedic implants: A potential role in osteolysis.Br J Rheumatol
33:309,1994.
24. Sande R: Radiography of orthopedic trauma and ftacture repair. Vet Clin North
An Small Anim Pract 29:1247, 1999.
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.
26. Brinker W, Flo G, Braden T, et al: Removal of bone plates in small animals. J Am
Anim Hosp Assoc 11:577,1975.
5. Excessiveperiosteal reaction seenat or distant from the fracture
site may be due to:
A. Rotational instability of the fragments.
B. Periostealstripping at the time of injury or surgery.
C. Osteomyelitis/bone infection.
D. A11of the above
E. None of the above
6, \{trich of the following is a radiographic warning sign that a
fracture is not healing normally? (Assume that a visible fracture
gap rs present.)
A. Demineralization of the fragment that ends at the fracture
srte
B. Smooth periosteal reaction located a slight distance from
the fracturegap
C. Linear radiolucency surrounding the shaft of an external
fixator pin
D. Scleroticfragment ends and a closedmarrow cavity
E. Minimal callus noted in fracture with rigid fixation

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.

29. lacobson A, Schrader S: Peripheral nerve injury associatedwith fracture or frac-

ture-dislocationofthe pelvis in dogs and cats;34 cases(1978 1982). I Am Vet Med
Assoc 190:569,1987.

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.

31. Stevenson S, Hohn R, Pohler O, et al: Fracture associatedsarcoma in the dog. I

Am V e t Me d A sso c1 8 0:1189,1982.

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

2. Which of the following would result in fracture healing with a

minimum of callus?
A. Poor postreductionapposition
B. Persistentmotion at the fracture site
C. Extensiveperiostealstripping
D. Comminuted fracture with numerous fragments
E. Rigid lracture6xation

3. Which of the following is true about an avascuiarbone frag-

ment in a comminuted fracture?
A. Undergoes permeative osteolysis Figure 1/t-28
I7 8 A P P E NDI CU L AR E D FE LIN E
S KE L ET ON -C A N INAN
comminuted radius/ulna fracture repaired using external coapta-
tion. Which statement best describesthe healing status at this time?
A. Nonunion, atrophic tyPe
B. Osteomyelitis with possible sequestrum
C. Healing fracture but fragments malaligned
D. Fracture-induced sarcoma highly likely
E. No evidence of healing-a bone plate should be applied
8. Examine the 6-week follow-up lateral radiograph of an oblique
humeral fracture that has been pinned (Fig. 14-29). Using this
single view, which statement best describes the healing status at
this time?
A. Nonunion, hypertrophic type
B. Osteomyelitis highly likely
C. Fracture has healed-remove the pin
D. Healing but incompletely healed fracture
E. None of the above
9. Examine the lO-week follow-up lateral radiograph of a radial
and ulnar transverse fracture repaired using a metasplint (Fig.
14-30). Using this single view, which statement best describesthe
healing status at this time?
A. Permeativeosteomyelitis is present.
B. Fracture is healed with poorly mineralized callus.
C. Atrophic nonunion is present.
D. Fracture is healed with disuse osteooorosis.
E. None of the above
10. Examine this 4-week follow-up craniocaudal radiograph of a
pinned tibial fracture (Fig. 1a-31) . Using this single view, which
statement best summarizes the healing status at this time?
A. Fragment distraction with probable low-grade osteomyelitis
B. Healing but incompletely healed fracture; loose wire
C. Delayed union present
D. Malunion with probable cerclagewire-induced ischemia
E. None ofthe above
Answers begin on page 727.
ffi CHAPTER

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.

Figure 154. Lateralview of the distalantebrachium. There is a mixed lytic

and b l a s t i cl e s i o ni n t h e d ista lr a d iu s.T h e co r te x is d e str o yedcrani al l yand
c au d a l l Vt h, e r ei s a n a c t ivep e r io ste arle a ctio na, n d a n in d istin cttransi ti onzone Figure 15-5. Lateralview of the antebrachium. Thereare multifocalregions
is s e e n o r o x i m a l l vb e t we e n n o r m a la n d a b n o r m a b l o n e . T h e metal l i cw i res of opaci tyw i thi nthe medul l ary
cavi tyof the di stalradi usand ul na.D i agnos i s :
were insertedafter a biopsy.Diagnosis:osteosarcoma. i di ooathiool
c vostol i bone
c i ntarcri on.

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.

Figurc 15-7. Lateralview of the proximalhumerus.There is a predominantlyproliferativelesionin

the metaphysisand the epiphysis.There is cortex destruction,active periostealreaction,and an
indistincttransitionzone distallybetween normaland abnormalbone. Therefore,the lesion is aggres-
sive. Other bone lesionswere not detected.The appearanceof the lesionis consistentwith neoplasia.
The focal lytic regionwas producedby a biopsy.Actinomycesspecieswas identified.The bone tesron
resolvedafter appropriatechemotherapv.
I82 A P P E NDIC U L AR E D FE LIN E
SK EL E T O N _ C A N INAN
thy, or clinical signs of systemic debilitation that support the
diagnosis of an infectious Process'but a biopsy of the bone lesion
is necessaryfor a definitive diagnosis.Solitary metaphysealmycotic
bone lesions are uncommon, but they do occur; any monostotic
metaphyseal aggressivelesion should be biopsied before a course
of therapy is selected.
Bacteiial osteomyelitismay also result in a monostotic aggressive
lesion. Bacterial osteomyelitis is most often the result of direct
contamination of the bone, such as may result from surgery and
trauma, rather than being hematogenous' Thus, the location of
bacterial osteomyelitis in the bone is more variable than the loca-
tion of primary tumors, and there is usually a history of previous
trauma br surgery. Additionally, the signalment and radiographic
distribution of the lesion are often sufficient for bacterial infection
to be distinguishedfrom neoplasia(Fig. l5-8).
assressivebone
I [],t:He
The major diagnoses to be ruled out for polyostotic aggressive
bone lesions are metastatic solid tumors and mycotic osteomyelitis.
Mycotic osteomyelitis is more common in dogs than it is in cats.
In general, patients with mycotic osteomyelitis tend to be younger
than patients with metastatic solid tumors. Mycotic osteomyelitis
is genirally of hematogenous origin, accounting for its polyostotic
naiure. Another consequenceof the hematogenous origin of my-
cotic osteomyelitis is a metaphysealdistribution of lesions because
of the rich blood supply in this region of bone. Diaphyseal lesions,
however, do occur.
Figure 15-8. Lateralview of the tibia of a 6-month-olddog taken 3 weeks
after externalfixation of an open distal tibial physealfracture.The limb is
s w o l l e n .w a r m , a n d pa in fu l.T h e r e is e xte n sivep e r io ste arle acti onal ongthe
b o n e . I n s o m e a r e a s, th e p e r io ste a lr e a ctio nh a s a p a lisadeappearance
(arrows),which is highlysuggestiveof bacterialosteomyelitisThe combination
of the age of the patient,the history,the extensionof the periostealreaction
alongthe entire shaft of the bone, and the palisadeappearanceof the perios-
teal reactionare most consistentwith bacterialosteomyelit;s.Neoplasiais not
a l i k e l yd i a g n o s i isn t his p a tie n t.Dia g n o sis:
b a cte r iaol ste o m yel i ti s
Mycotic osteomyelitisis most commonly identified in geographic
regions where predisposing fungi are endemic, for example, the
Southeast (blastomycosis)and the Southwest (coccidioidomycosis)
regions of the United States.However, infected dogs may relocate
to nonendemic areaswhere they may be examined by veterinarians
who do not have a high index of suspicion for fungal infections.
As noted earlier for solitary mycotic bone lesions, there may be
other clinical or radiographic evidence supporting an infectious
etiology for polyostotic aggressivebone lesions, but this is not
always true. Mycotic osteomyelitis should be considered in any
dog in which polyostotic aggressivebone lesions are identified
(Fig. 1s-e).
With animal cancer patients being treated more aggressivelyand
living longer, it has become apparent that metastatic bone cancer
is more common than was once thought. Any malignant tumor
has the potential to metastasizeto the skeleton but, in general,
bone metastasesfrom epithelial tumors are more common than
bone metastasesfrom mesenchymal tumors.T In dogs, mammary,
lung, liver, thyroid, and prostate cancersare tumors from which it
is not uncommon for bone metastasesto develop.s'e Metastatic
tumor sites in the skeleton arise hematogenously.Therefore, they
tend to have a polyostotic distribution (Fig. 15-10); ribs, vertebrae,
femur, and humerus are common sites.8'eIn long bones, both
diaphysealand metaphyseallocations are common. Metastatic bone
tumors are aggressiveradiographic lesions, and, as with primary
bone tumors, they may be sclerotic, mixed, or predominantly
osteolytic. Patientswith metastaticbone tumors are generally older;
they also usually have a history of primary tumor, making the
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
I Aggressive digital bone
I lesions
The digit is another location in which it may be difficult to
radiographically differentiate between infectious and neoplastic
causes for an aggressivelesion. Subungual tumors are relatively
common in the dog, with the most common type being squamous
cell carcinoma.lr Most subungual squamous cell carcinomas involve
large-breed dogs with black hair coats.lr't' Melanomas are another
common canine subungual tumor.t3 Inflammatory conditions of
the digit, for example, pododermatitis, also occur and these may
be difficult to differentiate radiographically from tumors. Radio-
 BoneTumorsVersusBone Infections 183

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
f,avebeen rep;rted.l4 It was found that tumors and pododermatitis
were fairly evenly distributed between the manus and the pes' Also,
the frequency of bone involvement was similar between subungual
tumors and pododermatitis 25148(52.1o/o) for pododermatitisand
33152(63.5%) for digital tumors. Regarding radiographic changes,
it was concluded thit pododermatitis could not be differentiated
from malignant tumors as both conditions resulted in aggressive
bone lesions. However, lesions characterizedprimarily by osteolysis
were more likely to be due to a malignant neoplasm.t' In another
study of dogs with digit masses,digit osteolysiswas seen in those
with all types of digit masses,but was more commonly associated
with squamous cell carcinoma'5 (Figs. 15-12 and 15-13).
Digitai tumors typically involve a single digit, but syndromes of
multiple-digit tumors have been described in dogst6'tt and catsts-"
(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

Figure 15-14. Dorsopalmarradiographof the manus fAl

and dorsoplantarradiographof the pes (B) of a 14-Vear-old
cat w i th sw ol l endi gi tsi nvol vi ng
al lfeet. In the manus there
,
i s sw el l i ngof the fourthdi gi tw i th l ysi sof the di s talphal anx
of that di gi t.In the pes,there i s l ysi sof the di s talphal anx
of the thi rddi gi tand l ysi sof the proxi malmi , ddl e,and di s tal
phalangesof the fourth digit;some reactivebone is present
on the proxi malphal anxof the fourthdi git.In radi ographs of
the thorax,mul ti pl el ung massesw ere pres ent.H i s tol ogi c
di agnosi sof the l ung and di gi tall esi onsi s s quamousc el l
carci noma. P resumablthe y di gi taltumor s repres entmeta-
statrcsites.
I8 6 A P P E NDI C U L AR E D FE LIN E
S KE L ET ON -C A N INAN

References D. No bone changes,only soft-tissue swelling

E. Multifocal medullary opacities
l. Alexander JW Patton CS: Primary tumors of the skeletal system Vet Clin North
Am 13 :1 8 1 ,1 9 8 3 . 3. 'v\hich radiographic appearancebest describesthe most com-
mon appearanceof primary bone tumors in the cat?
2. Bitetto WV, Patnaik AK, Schrader SC, Mooney SC: Osteosarcomain cats: 22 cases
(1974 1984).I Am Vet Med Assoc 190:91,1982. A. Primarily lytic
B. Primarily sclerotic
3. Quigley PR Leedale AH: Tumors involving bone in the domestic cat: A review of
C. Mixed lysis and sclerosis
58 cases.Vet Pathol 20:670,1983.
D. No bone changes,only soft-tissue swelling
4. Turrel JM, Pool RR: Primary bone tumors in the cat: A retrospective study of 15 E. Multifocal medullary opacities
cats and a literature review. Vet Radiol 23:152, 1982.

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.

9. The most common digital tumor in dogs is:

ffi Ouestions A. Squamouscell carcrnoma.
B. Melanoma.
1. Which of the following is the most common causeof a solitary C. Fibrosarcoma.
metaphysealaggressivebone lesion in a dog? D. Osteosarcoma.
A. Osteogenicsarcoma E. Hemangiosarcoma.
B. Lymphosarcoma
C. Fibrosarcoma 10. Which of the following radiographic changesis most suggestive
D. Chondrosarcoma of primary subungual neoplasia?
E. Hepatozoonosts A. Periostealproliferation
B. Multiple bone involvement
2. Which radiographicappearancebest describesthe most com- C. Soft-tissue swelling
mon appearanceof primary bone tumors in the dog? D. Osteolysis
A. Primarily lytic E. Soft-tissuecalcification
B. Prima rilysc ler ot ic
C. Mixed lysis and sclerosis Answers begin on p^ge727.
 C P TE R

16
4

Radiographic Signs of Joint Disease

' Graeme Allan

Signs of joint diseasethat may be distinguished radiographically
are listed in Table 16-l and illustrated in Figure 16-1. Many of
thesesigns are seenin more than one type of joint disease,that is,
they are not specific. Animals with joint diseasesthat are progres-
sive may have different signs when examined during different
phasesof the disease.
The examining clinician must determine whether lameness is
due to a monoarticular or a multiarticular problem. A hallmark of
immune-mediated joint diseasesis their polyarticular distribution.
The same finding applies to hematogenously disseminated septic
arthritis. Most other joint diseasesinvolve one or only a few joints.
Are there systemic signs of disease?Cats with feline chronic
progressivepolyarthropathy or Mycoplasmaarthritis have systemic
signs of illness, including transient fever, malaise, and stiffness as
well as lameness.Animals with signs of bleeding disorders and
concurrent joint pain should be examined for signs of hemarthro-
sis. Systemiclupus erythematosus (SLE) is a multiorgan disease,of
which polyarthropathy may be a mild clinical sign. These points
are mentioned only to underscorethat sound knowledge of joint
pathophysiologyis as important in the diagnosisofjoint diseaseas
is the ability to make and interpret radiographs of joints.
I Signs of joint disease
ated with the use of contrast arthrography. This technique has been
used to aid in the identification of chondral flaps and tears in
dogs with osteochondritis dissecansand of synovial hypertrophy
in villonodular synovitis.
Altered thickness of the joint space
The joint space is the region of soft-tissue opacity between the
subchondralbone of opposing weight-bearingsurfacesof a joint.
This spaceconsists of two layers of articular cartilage separatedby
a microfilm of synovial fluid. In early joint disease,synovial effu-
sion may causewidening of the joint space.As joint diseasepro-
gresses,attrition of articular cartilage results in a thinner appear-
ance of the joint space. Radiographs made while the patient is
weight bearing on an affected joint are required if changesin the
thickness of the joint spaceare to be assessed properly. Radiographs
of the recumbent animal are not adequate for this purpose. The
one exception to this rule may be when muscle contracture is
present, thereby compressing the joint space. Contracture of the
infraspinatus and quadriceps muscles, for example, reduces the
shoulder and stifle joint spaces,respectively.
Decreased subchondral bone opacity
The subchondral bone is separatedfrom the svnovial fluid bv an
intact layer of joint cartilage. Any diseaseprocessthat changesthe

Increased synovial mass

Any moderate increasein joint capsular or intracapsular soft-tissue
mass may be detected on good-quality radiographs. The joint
cartilage, synovial fluid, synovial membrane, and joint capsule
cannot be differentiated on survey radiographs becausethey have
the same radiographic opacity and therefore silhouette positively
with each other. In most joints, any increase in synovial mass
appears as periarticular soft-tissue swelling, which is identified
radiographically by the increasedradiopacity of affectedsoft tissues.
When the stifle is involved, the infrapatellar fat pad sign may be
used to evaluatesynovial volume. The normal infrapatellar fat pad
is readily identified on lateral stifle radiographs as a triangular
radiolucent region immediately caudal to the patellar ligament.
When stifle synovial mass increases,a combination of inflamma-
tory responseand effusion causesthe fat pad to become lessvisible.
If necessary,the joint cartilage and the synovium may be evalu-

Table 16-1. Radiographic signs of joint disease

Compressedinfrapatellafat pad
lncreasedsynovialtissue
Altered thicknessof the joint space
Decreasedsubchondralbone opacity
Increasedsubchondralbone opacity
Sub ch on dra bol ne c y s t f or m at ion
Altered perichondralbone opacity
Pe rich on drabl on y pr olif er at ion Figure 16-1. Graphicrepresentationof radiographicsigns of joint disease
Mineralizationof joint soft tissues fA l comparedw i th a normalj oi nt 1B ).1, Increased
synovi amas
l s ;2, peri c hon-
Intra-articularcalcifiedbodies dralosteophyte; and3, enthesophyte formati onare commonl yobs erv edradi o-
Join t d isp lacem ent graphi cchanges.E rosi onof the subchondral bonesurface(4)andj oi nt "mi c e"
(5)are si gnsseen l essoften,w hereasi ncreased subchondralboneopac i tv(6)
Join t ma lforma t ion
and subchondral bone "cyst" formati on(7)are si gnsof chronc j orntdi s eas e.

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.

Articular soft-tissue mineralization

As a consequenceof many chronic joint diseases,mineralization Table 16-3. Sesamoid bones visible on radiographs of
may occur within the joint capsule,within the synovial membrane, joints of the canine appendicular skeleton
or free within the synovial fluid. Occasionally,iarge accumulations Joint Name and/or location
of articular or periarticular calcific material may be observed.Large
Shoulder Clavicle(medial end of tendinous intersection
osteochondromas have been reported within the joints of dogs3
in m. brachiocephalicus)
and cats,a and intrameniscal calcification and ossification have Elbow Tendon of origin of m. supinatorlT
been observed in the stifle joints of cats.sPseudogout (or calcium Carpus T e n d o no f m . a b d u c t o rp o l l i c i sl o n g u s
pyrophosphate deposition disease),which causesmineralization of Metacarpo- Pairedpalmar sesamoidbones (locatedin the
articular and periarticular soft tissues,6'7has been reported in dogs. phalangeal tendons of insertionof the interosseous
muscles)
lntra-articular calcified bodies Single dorsal sesamoid(locatedin the extensor
tendons)
Small, well-defined articular and periarticular calcific opacities are Coxofemoral N o n e *
occasionallyobservedin dogs and cats. Such mineralized fragments F e m o r o t i b i a l Patella(tendonof insertionof m. quadriceps
are sometimes calledioint mice. Not all such fragments are free femoris)
within the joint, although they may appear so radiographically' Sesamoidbones of m. gastrocnemius(fabellae)
Intra-articular calcified bodies usually fall into three fairly distinct Medialhead
categories: alrrlsed fragments of articular or periarticular bone, Lateralhead
osteochondral components of a disintegrating joint surface, or Poplitealsesamoid(tendon of m. popliteus)
Tarsus Lateralplantar tarsometatarsalsesamoidbonel8
small synovial osteochondromas'6 (Table 16-2). They must be
Intra-articular tarsometatarsalsesamoidbone18
differentiatedfrom sesamoidboness(Table 16-3). Metatarso- Pairedplantar sesamoidbones
p h a l an g e a l S i n g l e d o r s a l s e s a m o i db o n e
Joint displacement
xSesamoid bone located in the iliopubic cartilage may be seen cranial to
When the normal spatiai relationship between the adjacent osseous the i Iiopubic em i nence.lo
components of a joint is disturbed, some type of displacement has

I Sesamoid bones
Sesamoidbones are commonly present adjacent to the elbow, stifle,
tarsus,and the metacarpophalangealand metatarsophalangeal
joints. If sesamoidbonesare not visualizedon a radiograph,it may
be because they are absent, or haven't ossified. The clavicle is
present in up to 960/o of large dogs and in all cats, but the
sesamoidsin the iliopubic cartilage were identified in only llo/o of
one group of Greyhounds. In the same group of dogs, the elbow
sesamoid,located in the tendon of origin of M. supinator, had an
incidenceof 3Io/o,the lateralplantar tarsometatarsal sesamoid50%0,
and the intra-articular tarsometatarsal sesamoid 27o/o,8b:ut the
popliteal sesamoidis ossifiedin B4o/oto 94o/oof dogs.q'oSesamoid
bonesare identified by their size,shape,and location. Occasionally,
displacedsesamoidsare regardedas a sign of muscular or tendinous
injury. Although this may be true, and has been reported in
conjunction with ruptured cruciate ligaments'gand trauma of the
tendon of origin of m. popliteuslL'2 and m. gastrocnemius,t3' ra
variation in sesamoidlocation may also occur in the absenceof a
pathologic situation.ls
I Gontrast radiography of joints
Radiographs using added contrast medium enhance visualization
of important intra-articular structures,such as the articular carti-
lage and synovium. Contrast radiographyhas been most usefu1in
evaluationof the canine shoulderjoint for evidenceof osteochon-
dritis dissecans.Other applications include evaluation of capsular
trauma, documentation of synovial hlpertrophy, and identification
of radiolucentjoint mice. Interest in methods of evaluatingdogs
r.vithbicipital tenoslmovitis and fragmented coronoid processeshas
resulted in renewed enthusiasmfor contrast arthrography.te-'?I process,ununited anconealprocess,hip dysplasia,patellar luxation,
\\tren compared with sonography, arthrography was considered a
more sensitivemethod of identifying abnormalitiesin the bicipital
tendon and intertuberculargroove of the humerus."
Either positive-contrastor negative-contrastmedium may be
used (Fig. 16-2). A diluted mixture of an isotonic positive-contrast
medium such as iohexol is recommended for positive-contrast
studies,the concentrationbeing reduced to 100 mg/ml of iodine
by the addition of sterile diluent. For average-sized dogs, an opti- idosis and chondro-osseousdysplasiaof ScottishFold cats. Estab-
mal volume of 2 to 4 mL is injected into the shoulderjoint.'3 This
dose can be varied for studies that evaluatethe bicipital tendon, in
rrhich the objective is to fi1l the bicipital tendon sheath; 0.4 ml/kg
body weight can be used for this application.l' For elbow arthrogra-
phy in dogs, the optimal volume was 2 mL in one report; in
that study, low volumes were preferred to higher vo1umes.'?o Strict changes,with osteoarthritis as the end result..t
adherenceto sterile technicue is mandatorv.When iodine concen-
trations greaterthan 100 mg/ml are used.the radiopaquecontrast
medium may camouflage underlying articular structures, rendering
them invisible.
Air or carbon dioxide may be used for negative-contrastarthrog-
raphy.When gas is used, it should be injected into the joint space
through a Millipore filter to ensure that it contains no particulate
ma lter o r micro or ganis m s .
I Sesamoid disease
-\ sl.ndromeof metacarpophaiangeal (MCP) sesamoidbone frag-
:nentation (Fig. 16-3) has been reported in severallarge breedsof
iiogs, but it occurs overwhelmingly in the Rottweiler breed.'a The
underlying cause appearsto be osteonecrosis2s of selectedsesa-
moids, although developmental,traumatic, and degenerativecon-
citions have also been cited as possibleprecipitatingcauses.There
=re eight palmar/plantar sesamoidson the four main digits of each
..i the fore/hindfeet, but sesamoidfragmentation affectsmainly the
:aimar sesamoidsnumberedtwo and seven.In an early description
..: the syndrome,the incidencewas 44o/oin one group of Rottwei-
-:rs.:6 In a prospectivestudy of 55 Rottweilers,the radiographic
-ncidenceof sesamoiddiseaseat 12 months of age was 73o/o,wrth
R adi ographiSci gnsof Joi ntDisease 189
an incidence of clinical signs attributable to sesamoid diseasein
650/oof affected dogs. Sesamoiddiseasewas identified as the cause
of forelimb lamenessin 507o of young Rottweilers.rT
Radiographic images obtained using dorsopalmar projections
usually allow identification of affected sesamoidbones, but oblique
lateral projections with the digits separated using traction may
provide additional information. Radiographically,fragmented sesa-
moid bones appear as a cluster of ossific fragments on the palmar
aspectof the joint, adjacent to an unaffected paired sesamoid.The
ossiclesare usually multiple, with rounded margins that conform
to a variety of shapes and sizes. In racing Greyhounds, clearly
defined transversesesamoid"fractures" have been reported, leading
to a belief that trauma is the cause of sesamoid fraementation in
this breed.'z8
Osteoarthritis
Osteoarthritis (degenerativejoint disease)is the most common
joint abnormality seen in small animai practice. It occurs most
frequently in the weight-bearingjoints of medium-sizedto large
dogs, although it may affect any synovial joint. The best example
of canine osteoarthritis occurs secondary to canine hip dysplasia.
The incidence of hip dysplasiavaries from breed to breed and in
many large breeds exceeds50%. The next most frequent locations
are the canine shoulder and stifle joints. Signsof shoulder osteoar-
thritis were identified in 33o/oto 50% of groups of dogs surveyed
either at necropsy or radiographically; 20o/oof dogs in another
surveyhad evidenceof stifle osteoarthritisat necropsy.2,2e'30
Osteoarthritis may be primary (idiopathic) or secondary to a
developmental or acquired disorder. Examples of canine develop-
mental disorders include osteochondrosis,fragmented coronoid
achondroplasia, and conformational disorders such as valgus and
varus deformities of the carpus. Acquired disorders capabie of
causing osteoarthritis in dogs include trauma, joint instability,
epiphysealaseptic necrosis,and acquired postural or conforma-
tional defects such as joint malalignment after fracture repair.3r
Primary causesof articular cartilage degeneration, and consequent
osteoarthritis, in cats include the storage diseasemucopolysacchar-
lished secondarycausesof feline osteoarthritis(Fig. l6-a) include
developmental and traumatic conditions that alter joint stability,
and dietary (hypervitaminosis A) and neuropathic causes(diabetes
mellitus). Many infectious and immune-based arthropathies alter
the integrity of articular cartilage, leading to a cascadeof articular
The initial stages of osteoarthritis are asymptomatic and thus
are not typically detected radiographically. The first pathologic
change is a mild nonsuppurative synovitis, accompanied by a sig-
nificant increase in the volume of synovial mass. Focal articular
cartilage degenerationfollows. The joint spacemay appear widened
during this stage.33In the coxofemoral joint, sprovial effusion
induces joint laxity, which appearsradiographically as subluxation.
The presence of hip laxity is a powerful indicator of the risk
of development of coxofemoral osteoarthritis.3oWorkers studying
passivecoxofemoral joint laxity, as quantified by a unitless distrac-
tion index (DI), reported a strong correlation betweenthe DI and
subsequentdevelopmentof degenerativejoint disease.In four
breeds studied (Borzoi, German shepherd, Rottweiler, and Labra-
dor retriever), the likelihood of coxofemoral osteoarthritis varied
with the breed and with the DI. Interestingly, the threshold DI,
below which coxofemoral osteoarthritis is unlikelv to occur. is
different for the different breeds. For the German shepherd, the
threshold DI is 0.3; it appearsto be higher (0.4) for the Labrador
retriever and Rottweiler.3+37
Radiographic changesvary according to the stageof the disease.
As the joint cartilage becomes thinner, several pathologic changes
take place. The most readily recognizable change is enthesophlte
and osteophyte formation, which follows neovascularizationof the
I9 0 S KE L ET ON -C A N INAN
A P P E NDI C U L AR E D FE LIN E

Figure 16-2. Contrastarthrography. A, Lateralnoncontrastradio-

graph of a normal stifle. 8, Negative-contrast arthrographyof the
sti fl ei l l ustrated
i n A . Tenmi l l i l i ters
of al rw as i nj ectedi ntothe cra nl al
aspectof the j oi nt space (1). N ote the caudalj oi nt sac (2), the
meni scii 3), and the ai r i n the bursasurroundi ng the tendonof the
extensordi gi toruml ongusmuscl e(4).A i r i s al sovi si bl ei n the bu rs a
of the popl i teusmuscl ethat i s adj acentto the popl i tealsesam oi d
(5). C A positive-contrast arthrogramof the contralateral stifle was
achlevedby injectlng10 ml of iohexoli60 mg/ml of iodine).Addi-
ti onali ntra-arti culfeatures
ar demonstrated bv thi s techni ouei ncr uoe
the crani al(6) and the caudal(7) cruci atel i gamentsi l i nearfi l l i ng
defects)and the articularcartilage(8).

chondrosynovial junction with resultant fibrocartilage formation.
This fibrocartilage collar gradually ossifies with the formation of
perichondral new bone (Fig. 16-5). Enthesophytesdevelop on
non-weight-bearing surfaces and are eventually incorporated into
adjacent ligamentous or capsular attachments.3s' 3e
On radiographs obtained during weight bearing, continued attri-
tion of the articular cartilage may be detected as thinning of the
radiolucent joint space. Pathologic alteration of the subchondral
bone shelf, including eburnation, compression, and necrosis, may
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
in joints of small animals.2'3e
Affected joints exhibit decreased range of movement, which
results in increasedloading of the diminished weight-bearing sur-
face. The combination of increased load, diminished subchondral
strength, and loss of shock-absorbing cartilage results in alteration
in the shape of the subchondral bone table. This remodeling of
subchondral bone is complemented by the addition of peripheral
new bone in the form of perichondral osteophytes.Altered shape
of the osseouscomponents of affected joints is readily identified
radiographically.3'g
The gamut of the radiographic changes seen in
degenerativejoint diseaseis outiined in Table 16-4.
I Hip dysplasia
The term hip dysplasiarneansabnormal development of the coxo-
femoraljoints. Hip dysplasiaoccurs principally in large dogs but
 R adi ographiSci gnsof Joi nt Disease l9l

Table 164. Radiographic signs of osteoarthritis

Synovial effusion
I n i t i a lw i d e n i n g ,t h e n t h i n n i n g ,o f t h e r a d i o l u c e n jto i n t sp a ce
Perichondralenthesophyteformation of non-weight-bearing
surlaces
Increasedsubchondralbone opacity
R e m o d e l i n go f s u b c h o n d r a lb o n e
Mineralizationof intra-articularand periarticularsoft tissues
Subchondralcyst formation (rare)
Subluxation(of the coxofemoralioint)

The earliest recognizable change in the coxofemoral joints is

joint laxity. This may be palpated (Ortolani's sign, Barden's lift
method) or visualized radiographically (Figs. 16-6 and 76-71.2t,
aa'asSubsequent radiographic changes
are those of osteoarthritis
(Fig. 16-8). The order of subsequentchangesis (1) perichondral
osteophyte formation, (2) remodelins of the femoral head and
neck, (3) remodeling of the acetabuluir, and (4) increasedopacity
of subchondral bone of the femoral head and acetabulum. An early
and sensitive sign of new bone formation has been described.ru
Solitary bony enthesophl.teson the caudal aspect of the femoral
Figure 16-3, Dorsopalmarprojection jointsof
of the metacarpophalangeal neck may be visuaiized as an opaque line (Fig. 16-9) directed
a dog.Thereareeightpalmar metacarpophalangeal
sesamoid bones,two of distally rather than around the femoral neck; this line has been
which(numbers 2 andl) are characterized
by multipleosseousfragments. called the "Morgan" line in recognition of the person who first
Interpretation:
fragmented sesamoidbones. described it. Because it is sometimes evident in animals whose
coxofemoral joint laxity is camouflaged on the extended view, it
should be regarded as an early and significant sign of coxofemoral
also affectssmall dogs and cats.The incidence in males and females degenerativejoint disease.As the degenerativephase advances,the
is similar. Usually, the condition is bilateral, but unilateral hip femoral head loses its spheroidal shape and becomes flattened
dysplasia has been reported in about llo/o of dogs radiographed along its articular surface. The femorai neck becomes thickened,
using the extended ventrodorsal projection. and the surface of the neck becomes irregulaE owing to a growth
Hip dysplasia is an inherited disorder. Heritability estimates of a collar of perichondral osteophytes.The acetabulum loses its
range from 0.2 to 0.6. With the use of more sensitiveradiographic cup-like shape and becomes shallow. Increased bone opacity of
techniques, the estimated heritability in German shepherds has subchondral articular surfacesrepresentsbone sclerosis,a response
been raised from 0.46 to 0.61.a0'ar Environmentalfactorsinfluence to cartilage thinning. A variable degreeof coxofemoral subluxation
the phenotypic expressionof hip dysplasia.n2 The role of nutrition is always present, and coxa valga is common. Subchondral ryst
has been studied extensively.Overnutrition is regarded as one of formation is an infrequent manifestation of degenerative joint
the principal nongenetic factors that influence the expression of diseasein small animals but mav occasionallvbe observed.
canine hip dysplasia." Hip dysplasiais a developmental,age-related The incidence of hip dysplasia in domestic shorthaired cats,
disorder; it is not present at birth. A variable amount of time must based on standard hip radiography, has been estimated at 6.6o/o.a7
elapse before radiographic changes are manifest. Once present, The incidenceis higher in purebred cats(12.3o/o),with some breeds
these radiographic changesusually progress as the affected animal such as the Maine coon cat having an incidence of l}o/o lo 2lo/o.a7,a8
ages. When passivecoxofemoral laxity is evaluatedusing stressradiogra-

Figurc 164. Craniocaudal (left)and mediolateral (right)projec-

t i o n s o f a f e l i n ee l b ow.Exu b e r a npt e r ia r ticu lanre w b o n e fo rma-
t i o n i s p r e s e n ta r o un dth e e lb o w. On th e la te r a p l r o je ction, an
u n e v e nr a d i o l u c e nj ot in t sp a cein d ica te sp o o rlo in t co n g r u it y.In-
t e r p r e t a t i o no:s t e o a r th r itis.
iF r o mAlla nGS: Ra d io g r a p hfeica tures
o f f e l i n e j o i n t d i s e ase s.Ve t Clin No r th Am Sm a llAn im Pract
3 0 : 2 8 1 - 3 0 2 . 2 0 0 0 .)
Ig 2 E D FE LIN E
A P P E NDI CU L ASRKE L ET ON -C A N INAN

:GG
::a

Figure 16-5. A and B, A 7-year-old

Germanshepherdhadchroni cw el ght-
beari ngl amenessof the ri ght pel v i c
l i mb. P eri chondraloste ophy tesand
enthesophytesare vlsibleon the distal
femur and the proxi malti bi a.S y nov i al
effusi on and subchondralbone ero-
si on (l ateralti bi alarti cul ar
s urfac e)are
al soevi denr.The presen c eof a promi -
nent osteophyteat the ori gi nof the
crani al cruci ate l i game nt s ugges ts
these changes are sec ondary to
chroni c j oi nt i nstabi li ty ori gi nal l y
causedby cruci atel i ga menttrauma.
C-E Degenerative joint diseasein the
elbow of a 2-year-oldRottweiler.Os-
teophyteson the cranialaspectof the
head of the radius/C/ and on the me-
dial edge of the coronoidprocess of
the ulna /D, and enthesophyteforma-
tion on the anconealprocess /E/ are
degenerativechangesoften seen sec-
ondaryto the fragmentedmedialcoro-
nordprocess.
 R adi ographiSci gnsof Joi nt Disease 193

Figure 16-6. Normalmaturecoxofemoraljoint. Note that two thirds of the

f e m o r a l h e a d l i e s m e d ia lto th e d o r sa l e ffe ctive a ce ta b ul armargi n (smal l
arrows).The cranialmarginof the femoralhead is separatedfrom the adjacent
a c e t a b u l u mb y a f i ne r a d lo lu ce nlin
t e ,wh ich r e p r e se n tsth e radi ol ucentj oi nt
cartilageand a microfilmof synovialfluid (openarrow).fhe flattenedportion
of the femoral head is normaland representsthe fovea capitisfemoris /so/id
arrow).

Figure 16-8. Advanced hip dysplasia.The acetabulumand the femoral

headhaveundergone advancedremodel i ng.
Osteophytes h av eformedon the
femoralneck and headas w el l as on the crani aleffecti v eac etabul ar margi n.
New bone formationhasfilledthe acetabularfossa,and the opacityof acetabu-
l arsubchondrai bonei s i ncreased.
Theseare easi l yrecogni z ed
s i gnsof degen-
erati vei oi ntdi sease.

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

phy, the overall incidence of feline hip dysplasia may be as high

as 32o/o.ae
Radiographic criteria for diagnosing feline hip dysplasiainclude
the presence of signs of coxofemoral subluxation, enthesophlte
formation on the acetabularmargins, and remodeling and degener-
ative changes of the femoral head and neck (Fig. 16-10). Unlike
canine hip dysplasia, most degenerative changes in cats appear
on the craniodorsal acetabular margins, with a low incidence of
degenerativeremodeling reported on the femoral head and neck.
The optimal method of screening canine coxofemoral joints to
quantifr dysplastic changes is disputable. Phenotypic screening
programs used internationally relied on assessmentof the extended
ventrodorsalradiographicprojection (Fig. 16-11), although it has
long been recognized as an insensitive indicator of coxofemoral
joint laxity. To reliably identif' coxofemoral joint laxity, a stressed
ventrodorsal projection is used. With the femurs placed in a dis-
tracted position50(Fig. 16-12), coxofemoral laxity can be quantified
and the calculated laxity index (distractive index, or DI) used to
rank individual dogs within their breed with respect to hip joint
tightness/looseness.The DI is also a reliable indicator of the likeli-
hood of future coxofemoral degenerativechanges.This information
can be obtained at a much earlier age using distraction radiography
than with the standard extended ventrodorsal projection'
Most screeningprograms require that the extendedventrodorsal Figure 16-11. Extended projection
ventrodorsal joints
of the coxofemoral
Foundation
iOrthopedic for AnimalsIOFAIpreferred
view).Notebilateralsym-
radiograph of the coxofemoral joints be made and submitted for metryof the pelvisandparallel jointsappearto be
femurs.Thecoxofemoral
evaluation. The method of obtaining the projection required by normal.
Couatesy of Dr.lanRobertson.)
the Orthopedic Foundation for Animals (OFA), which is similar to
the projections used by other screening programs internationallS
has been described in detail.s' With the dog in dorsal recumbency'
the hindlegs are extended with the femurs parallel and the stifles the cranial surface of the distal femur. The x-ray beam should be
rotated inward, so that the patellae are located over the middle of centered over the coxofemoral joints, and the radiograph should
include the entire pelvis and the femurs. The pelvis must appear
symmetrical in the radiograph, without evidence of pelvic rotation
(seeFig. 16-11). Although satisfactoryradiographicquality may be
achieved without the assistanceof chemical restraint,s2failure to
anesthetize the subject may decreaseradiographic sensitivity for
signs of coxofemoral joint lo.ity.$ Becausethe extendedventrodor-
sal projection is an insensitive method of detecting signs of coxo-
femoral subluxation,5O,sa care must be taken to ensure accurate
subject positioning and radiographic quality.

Figure 16-1O. A-D, Felinehip dysplasia.Varyingdegreesof coxofemoral

subluxation(B and O are comparedwith a "normal" iA) feline coxofemoral
joint. Degenerativechanges,with osteophyteformation(arrow)on the cranial
ef f e c t i v ea c e t a b u l amr a r g in ,fo llo w la te r ( D. ( F r o mAlla n GS: R adi ographi c
f eatu r e so f f e l i n ej o i n t d ise a se s.Ve t Clin No r thAm Sm a llAn im Pract30:281-
302.2000.\
Figure 16-12. Neutralventrodorsaldistractionprojection(PennHlPview).
Bilateralcoxofemoralsubluxation{laxity)is evident.This radiographis of the
samedog as that i n Fi gure16- 1'1. (C ourtesy
of D r. l an R oberts on.)

Figure 16-13. The distractedPennHlPview is achievedby hold-
ing a rubberizeddistractiondevice between the patient'sthighs,
w i t h t h e f e m u r s h e ld a t 9 0 d e g r e e sto th e p e lvis.T h e fe m ursare
g e n t l yp r e s s e da g a in stth e d istr a ctodr u r in gth e r a d io g r a p hiexpo-
c
SUTE,
The PennHIP method3a,3s' s0also requiresthe dog to be placed
in dorsal recumbency.The femurs are placed in a neutral position,
to duplicate standing. This neutral position avoids spfualtensioning
of the joint capsule, a significant disadvantageof the OFA projec-
tion. The hindlimbs are held with the femurs neutrally positioned,
and a radiograph is made while the coxofemoral joints are com-
pressed,to obtain an image of the coxofemoral joints at their most
congruent position. A distraction device is then placed between
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
tlvo views of the hips are compared, and any coxofemoral laxity is
quantified by a unitless measure,the DI. A third (OFA) projection
is made, so that secondarysigns ofhip dysplasia,such as degenera-
tive joint disease,can be evaluated (Fig. 16-14).
The PennHIP method has several inherent advantagesover the
traditional (OFA) method of evaluating the coxofemorai joints
(Table 16-5). First, it quantifies joint laxity, which is generally
accepted as the beginning, and probably the cause,of subsequent
degenerative changes. Second, the examination can be done on
young dogs. The predictive value of the DI is constant after 6
months of age, thereby providing invaluable information to breed-
ers when selecting their stock. Third, the technique predicts a DI
below which degenerativechangesare unlikely to occur. Converseiy,
there appears to be a direct relationship between the DI and the
subsequent development of osteoarthritis when the DI is greater
than 0.3 (for German shepherds) or 0.4 (for Labrador retrievers
and Rottweilers).
Figure 16-14. A-C, A completed PennHlP study with the
coxofemoraljoints in the extended (A), neutralcompressed/8,/,
and distracted/C/ prolections.Note the amount of coxofemoral
s u b l u x a t i odni s c l o s edin th is d o o in th e d istr a cte d
Dr o ie ctio n.
R adi ographiSci gnsof Joi nt Disease t 95
A variant of the PennHIP method has recently been described,
in which the Ortolani maneuver is simulated with the dog in
dorsal recumbency.55 This method disclosescraniodorsal and lateral
coxofemoral laxity, which is defined by a subluxation index (SI).
The SI is essentially similar to the DI derived by the PennHIP
method. This new stresstechnique confirms the findinss of penn-
HIP research-thatthe standari OFA method ,,o1 allow for
detectionof coxofemorallaxitv. -uy
I Trauma that involves the
I osseous components of joints
Any fracture that communicates with a ioint space is an articular
-be
fracture (Fig. 16-15). Articular fracturesmust diagnosedaccu-
rately to ensure appropriate surgical reduction and stabilization.
Radiographic examinations should include two projections made
at right angles to one another (Fig. 16-16). To these should be
added oblique views and projections during flexion and stress,
when needed. These additional proiections are of most value when
chip or avulsion fractures are suipected or when the osseousstruc-
tures of interestare superimposedon other osseousstructures.
Articular fractures occur frequentlv in immature animals because
of the incidence of physeal and epiphysealtrauma in these patients.
Becausethe proximal femoral physis is intracapsular, all femoral
capital physeal fractures are intra-articular fractures (Fig. 16-17).
In other joints, physeal fractures that involve the joint are usually
classifiedas Salter type III or IV fractures.s6
I9 6 A P P E NDI CU L AR E D FE LIN E
SK EL E T O N _ C A N INAN

Tabl; 16-5. Gomparison of OFA and pennHlP methods

for hip dysplasia radiograPhY
Extended ventrodorsal proiection
Advantages
Currentlythe most popular screeningprogram
internationally.
Does not require specialtraining or any accessory
eq uip men t.
On ly on e rad iog rap hr equir ed.
Has amasseda large databaseof informationabout the
coxofemoralphenotype.
Animals can be radiographedwithout personnelexposure.
Disadvantages
Inaccuratein young animals;accuracyincreaseswith age;
optimal time to radiographis 24-36 mo.
An insensitivemethod of identifyingcoxofemoraljoint laxity'
Requiresrigid applicationto achievebeneficialresultsin
breedingprograms.
Techniqueof extendingthe femurs camouflagessigns of joint
laxity by spiral tensioningof the joint capsule.
PennHlP distraction proiection
Advantages
A valuablescreeningmethod for breedersbefore litters are
placedin h ome s ( as ear lYas 16 wk ) .
An accuratemethod of predictingdysplasticchangesin
yo un g an imals,fr om 6 m o.
A sensitivemethod availablefor identifyingjoint laxity.
Generatesa unitlessindex (distractionindex) that can be
used to predictwhether or not osteoarthritiswill develop'
Has a greater heritabilitythan the OFA method.
Disadvantages
Requiresspecialtraining to certify users.
Re qu iressp eciale quiPm ent . Figure 16-15. A 3-year-old Germanshort-hair pointerwith acuteonsetof
non-weight-bearingiameness of the leftpelviclimb.Thereis a fracturethrough
Multiple radiographicprojectionsrequired. ridgeof the lalus(arrow). Diagnosis:
articularfractureof
the lateraltrochlear
Personnelexposureduring radiographicexposuredifficultto thetalus.{Courtesy of the Universltyof Sydney.)
avoid.

OFA, Orthopedic Foundation for Animals

Premature physeal closure may follow repair of Salter fractures
and is observed within 2 to 3 weeks of surgery. It should be
regarded as a potential consequence, regardless of the type of
physeal trauma, and periodic radiography is advised to minimize
ihe problems associatedwith undetected premature physealclosure'
and identifuing arrrlsed osseousfragments. A useful technique for
radiographic assessmentof a sprained joint is stress radiography
(Figs. 16-18 and 16-19). In practice,this techniqueinvolvesappli-
cation of force to the joint in question to demonstrate displacement
of its osseouscomponents. The forces applied are the same stresses

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

Figure 16-17. Becausethe femoralcapitalepiphysisis entirely

i n t r a c a p s u l aarn, y f r actu r ein vo lvin th
g e fe m o r a lh e a d ,a s illu strated,
i s a n a r t i c u l afrr a c t u r e .

Figure 16-18. An 8-month-oldBurmese cat was lame in the left

pel vi cl i mb. A crani ocaudal
radi ograph/A / w as normal .In a s tres s ed
craniocaudalradiograph1Bl,widening of the lateralaspect of the joint
spacew as apparent.D i agnosi s:rupturedl ateralco l aterall i gament.
I9 8 A P P E NDI CU L ASRKE L ET ON -C A N INAEN D FE LIN E
Figure 16-19. A, A neutral lateral radiographof a racing
w as per-
G r e y h o u n da p p e a r sn o r m a . B, Str e ss r a d io g r a phy
f o r m e d ,w hlch a llo we dld e n tifica tioonf in sta b ility of the proxi -
m a l i n t e r t a r saiol in t.
to which the joint would be subjected in normal daily activity and
are defined as compressive,rotational, traction, shear, and wedge
forces (Fig. 16-20).Y
An excellent example of a compressivestressis a radiograph of
a joint during weight bearing. Ligamentous trauma, as in carpal
hlperextension injuries, is readily detected by this technique. The
cranial drawer sign seen in cranial cruciate ligament trauma is a
practical example of a shearing stress. It is stress that is used
routinely in clinical examination of the stifle' The same manipula-
tive procedure may be applied to the stifle during radiography.
Tlaction stressinvolves pulling the osseouscomponents of the joint
away from one another. One useful application of traction stress
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:
181 7 7 7 .1 9 8 2 . )
involves capital physeal fractures of the femoral head. When trac-
tion is applied to the femur in the extended ventrodorsal position,
capital physeal fractures are easyto identiff.
A technique employing traction stress has been described for
identi$zing medial scapulohumeral joint instability in small dogs.
With the patient in lateral recumbency, nontraction and traction
radiographs are made of the shoulder joint. A significant increase
in the shoulder joint spacehas been identified as a sign of medial
shoulder joint instability.s8Traction and wedge stressesare usefu1
for examining joints for small avulsion fractures and intra-articular
joint mice. Unilateral trauma to collateral ligaments of the elbow
and stifle may be disclosedwith the use of wedge stresses.Because
Appltcationsin small animalpractice.J Am Vet Med Assoc

Figure 16-21, An 8-year-old maleAustraliancattledog had neurologlcsigns
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
compressed b y s y n oviael ffu sio nNo . teth e b u lg in gca u d aco l mpartment
stifle joint (arrows).Discospondylitis was identifiedin radiographsof the tho-
racicspine.Laboratorydiagnosis:septicarthritis-basedon isolationof Staphy-
lococcusaureusfrom the synovia fluid.
stress radiography requires that personnel hold the patient during
x-ray exposure, utmost care must be taken to ensure that such
persons wear appropriate protective clothing.
I Hemarthrosis
Intra-articular hemorrhage may occur in dogs with coagulopathies
or after joint trauma. Hemarthrosis was reported in a dog with
suspected warfarin toxicosis.seOther coagulopathies in the dog
that may cause hemarthrosis include hemophilia A and B; von
Willebrand's disease;deficienciesin factors VII, X, and XI; and liver
disease.Isolated,infrequent episodesof intra-articular bleedingdo
not significantly alter the articular cartilage. Repeatedhemorrhage
may lead to severedamage to the cartilage as weli as the subchon-
dral bone.
Affected animals suffer severe non-weight-bearing lameness of
Figure 16-22. An 8-year-oldmale Australiancattle
d o g h a d s t i f l es w e l in g a n d p a inth a t p e r slste da fte r
r e p a i ro f a r u p t u r e dcr a n la cr u cla telig a m e n t.A a n d
B , S u b c h o n d r ab lo n ee r o sio nln vo lve sth e m e d ia co
l n-
d y e o f t h e t b i a a n d th e ' e m o r a l co n d yle s 1 so lr d
arrows).Periarticular new bone formationis also evi-
dent (openarrod. Notethe concurrentmedialpatelar
luxation.Laboratorydiagnosis:septicarthritis-based
on isolationof Staphvlococcus aureusfrom the syno-
v i a lf l u i d .
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,
discospondylitis,or omphalophlebitis) or in conjunction with some
systemic diseases(as in Mycoplasma arthritis, canine leishmaniasis,
of the or feline caiiciviral lameness).6'?' 63Polyarticular infectious arthritis
must be differentiatedfrom immune-mediatedjoint disease.Mo-
noarticular infectious arthritis most likely results from extension
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.
The earliest radiographic changesare synovial effusion and in-
creasedsprovial mass, which represent an inflammatory response
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
the stifle is the infrapatellar fat pad. When the fat pad silhouette is
displaced cranially, becomes unclear, or is lost, sprovial effusion is
present. In untreated infectious arthritis, joint cartilage destruction
follows synovial effusion and is followed by subchondral and peri-
chondral bone destruction (Figs. 16-22).
Specific radiographic featuresof infectious arthritis become con-
spicuous after the articular cartilage is destroyed and subchondral
osteomyelitis is established.It has been reported that destruction
of the femoral head was noted radiographically 4 weeks after the
onset of ciinical signs of coxofemoral infectious arthritis.6, The
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
2 O O A P P E NDI C U L AR
S KE L ET ON -C A N INAN
E D FE LIN E
Table 16-6. Progression of radiographic signs of
infectious arthritis
Increasedsynovial mass, indicatingsynovial effusionand
widened radiolucentjoint space.
Diminishedradiolucentjoint space,indicatingdestructionof
articularcartilage.
Loss of the smooth surfaceof the subchondralbone olate-
an early sign of infectiouspenetrationof subchondralbone.
Osteolucentsigns of destructionof subchondraland
pe rich on dra b
l on e, whic h is us uallyhighlight edby a
peripheralborder of increasedosseousopacity.
In advancedinfectiousarthritis,weight-bearingsurfacesmay
collapse,causingdistortionof joint architecture.
articular cartilage is destroyed.Radiographsobtained during weight
bearing are needed to detect this change. Destruction of the sub-
chondral bone plate and subsequent subchondral osteomyelitis
cause the margins of the joint space to appear uneven or ragged.
Continued subchondral bone destruction produces large cystic sub-
chondral radiolucent spaces.Bone sclerosisadjacent to the osteo-
lytic bone appears as increased osseousopacity, a sign of osseous
inflammatory responseto the infection (Table 16-6).
Increasingly,septic arthritis is being identified in joints that have
well-established osteoarthritis. Initial radiographs reveal changes
consistentwith degenerativejoint disease,often leading to inappro-
priate therapy for the infection. Radiographs made 2 to 4 weeks
later reveal more aggressivesigns of periosteal new bone formation
and intra-articular bone destruction.6aSeptic arthritis should be
suspected when acute lameness and joint pain are identified in
individual animals whose osteoarthritis has previously been well
controlled.
I Rheumatoid arthritis
Rheumatoid arthritis is a severe,progressive,erosive polyarthritis
that has been reported in dogs.6' A similar condition has been
identified in cats.66,67
Radiographic changes usually occur in distal joints of the ex-
tremities. The more proximal large joints (stifle and elbow) are
occasionallyaffected.Synovial effusion occurs initially. Radiographs
made early in the course of the diseaseare typically characterized
by nonspecific soft-tissue swelling around affectedjoints. The joint
capsule may be distended. The first radiographic signs of an osse-
ous pathologic process may be detected several weeks after the
onset of clinical signs. Initial changes are mild but, as would be
Crrlr
:-ii&l
expected in a progressive disease,the magnitude of radiographic
abnormalities becomes more obvious as the diseaseadvances.
The progression of radiographic changesincludes (l) perichon-
dral decreasedbone opacity, (2) subchondral bone destruction and
cyst formation, (3) signs of perichondral osteolysis and erosion
(Fig. 16-23), (4) narrowing of the joint space, (5) progressive
decreasedopacity of epiphysesadjacent to affected joints, (6) de-
struction ofsubchondral and perichondral bone, (7) mushrooming
of the ends of the metacarpi and metatarsi (which occurs in
advanced arthritis and represents collapse of subchondral bone),
and (8) varying degreesoiloint subluxation and luxation, also in
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
I Systemic lupus
I erythematosus
Systemiclupus erlthematosus (SLE) is a multisystemic diseasethat
affects dogs of all breeds as well as cats. The disorder has a
variety of clinical manifestations, including polyarthritis, anemia,
nephropathy, skin disease,pericarditis, myocarditis, and lymphade-
nopathy.6q6eThe diagnosis of SLE is complicated, based on the
concurrence of clinical manifestations and seroloeic evidence of
the disease.
The immunopathologic features of SLE should be consistent
with the clinical involvement (e.g., if arthritis is present, immune
complexesshould be demonstrable in tissue biopsy samples).
The relative frequenry of the different clinicai manilestations
seenin SLE varies according to different authors. In one study, 121
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)
manifestations.6s
Arthritis that occurs in SLE is described as nonerosive and
effusive. Poiyarthritis (five or more joints affected) is usual, but
monoarticular and pauciarticular arthritis have been reported.
Clinically, affected animals are reluctant to move becausethey often
have a shifting lameness.Affected joints may be swollen, painful,
and warm. The joints most commonly affected are the carpus,
tarsus, metatarsus,stifle, and elbow.
Radiographic signs are usually absent or are minimal. In chronic
SLE, the joint space of affected joints may be narrowed, and the
joint capsule is distended. A mild periosteal response has been
reported at the junction of the joint capsuleand the bone. Contrast
Fi gure 16-23- A n 8-year-ol dmal e (neutered)C orgi
cross-breedhad non-weight-bearing lamenessof the right
forelimb,valgusdeviationof the left manus,and left car-
pal joint swelling and crepitus,A, Dorsolateral-palmaro-
medial projection(right carpus).There is extensivesub-
chondralerosionof the styloidprocessof the ulna and of
the articularsurfacesof the distalradiusand radialcarpal
bone (arrows).B, Lateralprojectionduringflexion.In addi-
tion to the changesseen in A, note the erosion of the
non-w ei ght-beari ng dorsal surfaceof the radl alc arpal
bone (arrow).Laboratorydiagnosis:canine rheumatoid
arthritis.(Courtesyof the Universityof Sydney.)
 R adi ographiSci gnsof Joi nt Disease 2O l

Figurc 16-24. A 2-year-oldmale domestic cat had progres-

s i v e , g e n e r ai z e d l a m e n e ss,wh ich wa s p r e ce d e db y fe ve r and
l a s s i t u d eR. e g i o n al ym l p hn o d e swe r e p a lp a b ly
e n la r g e dIn
. r adi o-
g r a p h sm a d e 1 m o nth a fte r o n se t o f th e cl n ica lilln e ss,th e re i s
p e r i o s t e anl e w b o n e fo r m a tio no n m a n y ta r sa lb o n e s.Su b chon-
d r a lo s t e o l v s i iss o r on o u n ce ind th e d ista lin te r ta r saalr ticua tions.
Some tarsal bones have foci of osteolysis.Peritarsalsoft-tissue
s w e l l i n gs e v d e n t . L a b o r a to rdyia g n o sis: fe lin ech r o n icp r o gres-
s i v e p o l y a r t h r i t i (sF. ro mAlla nGS: Ra d io g r a p hfe ica tu r e so f fel i ne
j o i n t d i s e a s e sV. e t Clln No r thAm Sm a llAn im Pr a ct3 A:2 8 1 -302,
2 0 0 0 . )( C o u r t e soy f th e Un ive r sity o f Syd n e y.)

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.

Periosteal proliferative form

Affected cats display clinical signs characterizedby fever, malaise,
and stiffness,which are followed by periarticular soft-tissueswelling
and regional lymphadenopathy.Radiographic changesmay be iden-
tified in affected joints after a few weeks of clinical illness. The
joints most commonly affected are the carpi and tarsi. The stifle,
elbow, shoulder, and hip joints are affected to a lesserextent.
During the first month, periarticular soft-tissue swelling is the
predominant sign. Swelling may be either intracapsuiar or extra-
capsular.One to 3 months after the onset of clinical signs,perios-
teal new bone production at points of joint capsular attachment
may be identified. During this phase,the bone adjacent to affected
joints may have decreasedbone opacity and a coarsetrabecular
pattern. Perichondralnew bone formation is pronounced 2 or 3
months after onset of the disease.
Extensive enthesopathy may bridge smalier joint spaces.More
severeradiographic manifestations include perichondral bone ero-
sion and formation of subchondral cysts. Narrowing of affected
joint spacesmay occur late in the disease.66 The radiographicsigns
of the periosteal proliferative form of feline chronic progressive
polyarthritis include periarticular soft-tissue sweliing, periosteal
new bone formation, perichondral enthesophyteproduction, peri-
chondral and subchondral erosion, subchondral cysts,osteopenia
Figure 16-25. The tarsus of a young cat with feline chronrcprogressve
of bone adjacent to affected joints, and narrowed joint spaces pol yarthri ti(From
s. of fel i nej oi ntdi s eas esV. et
A l l anGS : R adl ographifeatures
c
(Figs. 16-24 and 16-25). Arthrography has been used to detect C l i nN orthA m S mal l A ni mP racr30:281-302,2000.) (C ourtesof y the U ni v ers i ty
proliferative synovitis in affected joints.7'? of Svdnev.)
 R EL E T O N -C A N INAN
2 O2 A P P E NDI C U L ASK E D FE LIN E
rheirmatoid factor test, characteristic histologic changesseen on a
synovial biopsy, or both. Both of these test results are negative in
cats with feline proliferative polyarthritis."
Feline nonerosive polyarthritis
Two categoriesof nonerosive polyarthritis have been described in
cats.7l They are feline SLE and idiopathic polyarthritis (IP), the
latter having four subtypes: (1) uncomplicated polyarthritis; (2)
reactive polyarthritis, associatedwith a diseaseprocesselsewherein
the body; (3) enteropathic polyarthritis, associatedwith gastrointes-
tinal disease; and (4) malignant-related idiopathic polyarthritis,
associatedwith myeloproliferative disease.
Radiography is used to distinguish the erosivefrom the nonero-
sive form of feline polyarthritis. The latter group is identified as
having periarticular soft-tissue swelling, joint capsule distention,
and synovial fluid accumulation.
I Hypertrophic osteopathy
Hypertrophic osteopathy (HO) is a generalized'osteoproductive
disorder of the periosteum that affects the long bones of the
extremities (Fig. 16-26). HO is usually secondary to cardiopulmo-
nary diseaseor neoplasia.Most neoplasmsare pulmonary (primary
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.,
blastomycosis),intrathoracic foreign bodies, Diroflaria immitis in-
festation, and spirocercosis.
The pathogenesis of hlpertrophic osteopathy is incompletely
understood. The most consistent pathologic finding in affected
animals is increased blood flow to the extremities. This increased
flow results in an overgrowth of vascular connective tissue with
subsequentfibrochondroid metaplasiaand subperiostealnew bone
formation. New bone formation ty?ically commenceson the digits
and progressivelyextends toward the axial skeleton.
Periostealnew bone formation results in cortical thickening. The
periosteal surface appears nodular or spiculated when visualized
radiographically. When joints are involved, the bone surfacesthat
are not covered with cartilage are roughened, and large perichon-
dral osteophytesform.
I Villonodular synovitis
Villonodular sgrovitis is an intracapsular joint disorder character-
rzed.bynodular synovial hyperplasia,which is thought to represent
a responseof the s1'noviumto trauma. Experimentally, villonodular
synovitis has been reproduced in dogs by repeated intra-articular
injections of whole blood. Villonodular synovitis is an established,
although uncommon, disorder of humans that has also been re-
ported in horses and dogs.z:-zo
The radiographic signs of villonodular synovitis may be nonspe-
cific but include articular soft-tissue swelling aione or with erosion
of cortical bone at the chondrosynovial junction. These cortical
erosions may appear cyst-like, with slightly opaque borders. In
severe proximal femoral villonodular sgrovitis in humans, the
femoral neck has been described as looking like an apple core. The
articular cartilage and subchondral bone are not involved in the
diseaseprocess.Arthrography may be used to identifi; the intracap-
sular nodular massesof hlpertrophied synovium.
The differential diagnosis for perichondral erosive lesions, char-
acteristic of villonodular synovitis, should include s]movial osteo-
chondromatosis,rheumaloid arthritis, and ioint neoplasia.
I Synovial osteochondromas
Synovial osteochondromashave long been recognizedin the joints
of humans. These lesions are described as islands of cartilage that
are produced by the synovial membrane. Foci of cartilage become
pedunculated and may become separated from their pedicles to
form loose bodies within the joint.
The radiographic appearanceof mineralized synovial osteochon-
dromas varies. These lesions are usually well-defined, rounded,
often multiple intra-articular nodules of calcific opacity (Fig. 16-
27). Not all chondromas become calcified, in which instance, con-
trast arthrography may be necessaryfor their diagnosis.' Synovial
osteochondromasmay also arise from extra-articular foci of syno-
vial tissue(Fig. 16-28).
Figure 16-26, A 6-year-oldmale Australiancattle dog had swollen
paws and progressivelamenessfor 6 weeks. In the forelimb,there was
periostealnew boneformationon the radius,ulna,and metacarpalbones.
In the hindlimb,periostealnew bone formationwas noted on tarsaland
metatarsalbones.Histologicdiagnosis:hypertrophicosteopathysecond-
ary to pulmonaryneoplasia.
 R adi ographiSci gnsof Joi nt Disease 2O 3

;.-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

Figurc 16-30. Multipleradiolucentlesionsare evidenton both s des of this dog's

sti fl e.H i stol ogidi
c agnosi s:
synovi alsarcoma,

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.)

Synovial osteochondromashave been reported in the dogtt and
the cat.a,78Their cause is unknown, but the theory of synovial
metaplasia is generally accepted.These lesions have been reported
to causeseverelamenessin some dogs. Surgical removal of synovial
osteochondromas relieves clinical signs of joint pain and lame-
ness.77
Intrameniscal calcification and ossification have been reported
in the stifle joint of cats.sRadiographically,these lesions appear
similar to the reported appearanceof osteochondromaswithin the
feline stifle joint. Other conditions in cats in which intra- and
periarticular mineralization may be confused with synovial osteo-
chondromatosis are mild forms of mucopolysaccharidosistype VI
(MPS VI)D and hypervitaminosisA.3'?
I Joint neoplasia
The primary joint neoplasm,synovial sarcoma,arisesfrom primi-
tive mesenchymal precursor cells outside the synovial membrane
of joints and bursae.toThese tumors are uncommon in the dog
and are rare in the cat.81They occur most frequently in middle-
aged, medium-sized to large dogs. The most commonly affected
joints are the stifle and the elbow Synovial sarcomasgrow slowly
and are first noticeable as a homogeneoussoft-tissuemass that
involves or is near to a joint. Initially, radiographs reveal a mass of
soft tissue. Portions of the tumor may be calcified, with mineral
depositsappearingas hazy and punctate,or as linear streaks(Fig.
16-29).
Canine synovial sarcomas are more likely to invade adjacent
bone than their counterpart in humans. Initial bone involvement
appears as a spiculated periosteal response, followed by ragged
erosion of the cortical bone adjacentto the tumor. Destruction of
cancellousbone may be extensiveand most commonly occurs on
both sidesof the joint (Fig. 16-30). The tumor is locally invasive
with an unpredictable capacity to metastasize,s'? although distant
metastasis,particularly to the lungs, occurs in as many as one half
of reported patients.s0 Radiographicexamination of the thorax is
therefore mandatory in patients with suspectedsynovial sarcoma.
Many neoplasmsmimic the radiographic appearanceof slmovial
sarcomas(Fig. 16-31). In a recent study of joint neoplasms,syno-
vial sarcomaswere representedin only 8 (27Vo)cases.83 The other
neoplasms whose radiographic appearancewas similar to that of
synovial sarcomas included fibrosarcoma, rhabdomyosarcoma, fi-
bromyxosarcoma,malignant fibrous histiocytoma, liposarcoma,
and undifferentiated sarcoma.The once "pathognomonic" findings
of an intra-articular tumor with osteodestructivepotential affecting
the bones on either side of the joint cannot be assumedto be
caused by a synovial cell sarcoma. Histologic evaluation of the
lesionis mandatoryto establishits origin.
References
1. Basher AWP, Doige CE, Presnell KR: Subchondral bone cysts in a dog with
osteochondrosis.J Am Anim Hosp Assoc 24:321, 1988.
2. Morgan JR Pool RR, Miyabayashi T: Primary degenerative joint disease of the
shoulder in a colony of Beagles.J Am Vet Med Assoc 190:531,1987.
3. Flo GL: Synovial chondrometaplasia in five dogs. J Am Vet Med Assoc
200:943,1992.
4. Kealy JK, McAllister H: Diagnostic Radiology and Ultrasonography of the Dog
and Cat, 3rd ed. Philadelphia, WB Saunders, 2000, p 282.
5. Whiting PG, Pool RR: Intrameniscal calcification and ossification in the stifle
joints of three domestic cats. J Am Anim Hosp Assoc 21.:579,1985.
6. de Haan JJ,Anderson CB: Calcium crystal associatedarthropathy in a dog. J Am
Vet Med Assoc 200:943, 1992.
7. Short RP, Jardine lE: Calcium phosphate deposition diseasein a Fox Terrier. J Am
Anim Hosp Assoc29:363,1993.
8. Wood AKW, McCarthy PH: A study of irregularly occurring ectopic and sesamoid
bones in the dog. Vet Radiol 27:22,1986.
9. DeRooster H, van Bree H: Popliteal sesamoid displacement associatedwith cruci-
ate rupture in the dog. J Small Anim Pract 40:316, 1999.
R adi ographiSci gnsof Joi ntDisease 2O 5
10. McCarthy PH, Wood AKW: Anatomical and radiological studies of the iliopubic
cartilage in adult Greyhounds. Anat Histol Embryol 15:73, 1986.
ll. Pond MJ, Lasonsky JM: Avulsion of the popliteus muscle in the dog: A case
report. J Am Adm Hosp Assoc 12:60,1976.
12. Eaton Wells RD, Plummer GV Avulsion of the popliteus muscle in an Afghan
hound. J Small Anim Pract 19:743, 1978.
13. Chaffee VW, Knecht CD: Arulsion of the medial head of the eastrocnemius in the
dog. Ver M ed Sm al l Ani m C l i n 70:c 29.1975.
14. Robinson A: Atraumatic bilateral arulsion of the origins of the gastrocnemius
muscle. ) Small Anim Pract 40:498, 1999.
15. Rendano Vl Dueland R: Variation in location of sastrocnemius sesamoid bones
r fabel l aeti n a dog. I Am Vet M ed As s oc 173:200.1q78.
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.
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
Res46:2043,1985.
18. Wood AKW, McCarthy PH: Radiologic and anatomic observations of plantar
sesamoid bones at the tarsometatarsal articulations of Greyhounds. Am J Vet Res
45:2158,1984.
19. Barthez PY, Morgan JP: Bicipital tenosynovitis in the dog-evaluation with posi-
tive contrast arthrography. Vet Radiol Ultrasound 34:325, 1993.
20. Lowry IE, Carpenter LG, Park RD, et al: Radiographic anatomy and technique for
arthrography of the cubital joint in clinically normal dogs. J Am Vet Med Assoc
203:72, 1993.
21. Muir q Johnson ICA.:Supraspinous and biceps brachii tendinopathy in dogs. J Am
Anim Pract 35:239, 1994.
22. Rivers B, Wallace L, Johnson GR: Biceps tenosynovitis in the dog: Radiographic
and sonographicfindings. Vet Comp Orthop Traumatol 5:51,1992.
23. Muhumnza L, Morgan JP, Miyabayashi T, et al: Positive-contrast arthrography: A
study ofthe humeral joints in normal Beagle dogs. Vet Radiol 291157.1988.
24. Cake MA, Read RA; Canine and human sesamoid disease. Vet Como Orthoo
Tiaumatol 8:70,1995.
25. Robins GM, ReadRA: Diseasesof the sesamoidbones.In Bojrab MJ (ed): Disease
Mechanisms in Small Animal Surgery, 2nd ed. Philadelphia, Lea and Febiger, 1993,
p 1094.
26. Vaughan LC, France C: Abnormalities of the volar and plantar sesamoids in
Rottweilers.J Small Anim Pract 27:551,1986.
27. Read RA, Black AR Arnstrong Sl, et al: Incidence and clinical significance of
sesamoid diseasein Rottweilers. Vet Rec 130:533, 1992.
28. Davis PE, Bellenger CR, Turner DM: Fractures of the sesamoid bones in the
Greyhound. Aust Vet j 45:15, 1969-
29. Ljunggren G, Olsson S-E: Osteoarthrosis of the shoulder and elbow joints in dogs:
A pathologic and radiographic study of necropsy material. J Am Vet Radiol Soc
16:33,1975.
30. Tirgari M, Vaughan LL: Arthritis of the canine stifle joint. Vet Rec 96:394, 1975.
31. Marshall JL: Peri-articular osteophltes-initiation and formation in the knees of
the dog. Clin Orthop 62:37, \969
32. Allan GS: Radiographic features of feline joint diseases.In Watrous BJ (ed):
Veterinary Clinics ofNorth America. Philadelphia, WB Saunders,2000, pp 281-302.
33. Lust G, Summers BA: Early, asymptomatic stage of degenerativejoint diseasein
canine hip joints. Am J Vet Res42:1849,1981.
34. Smith GK, Popovitch CA, Gregor Tq et al: Evaluation ofrisk factors for degenera-
tive toint diseaseassociatedwith hip dysplasia in dogs. I Am Vet Med Assoc 206:642,
1995.
35. Smith GK, Gregor TP, Rhodes WH, et al: Coxofemoral joint luity ftom distraction
radiography and its contemporaneous and prospective correlation with laxity, subjec,
tive score, and evidence of degenerative.joint diseasefrom conventional hip-extended
radiography in dogs. Am I Vet Res 54:1020, 1993.
36. Popovitch CA, Smith GK, Gregor TP, et al: Comparison of susceptibility for hip
dysplasia between Rottweilers and German shepherd dogs. J Am Vet Med Assoc
206:648,1995.
37. Lust G, Williams AJ, Bufton-Worster N, et al: Joint luity and its association with
hip dysplasia in Labrador Retrievers.Am ) Vet Res 54:1990, 1993.
38. Marshall JL, Olsson S-E: Instability of the knee: A long-term experimental study
in dogs.J Bone loint Surg (Am) 531561,197I.
39. Sokoloff L: The pathology of osteoarthritis and the role of ageing. In Nuki I
(ed): The Aetiopathogenesis of Osteoarthritis. Tunbridge Wells, UK, Pitman Medical
Publishing,1980,pp 1-1s.
206 S KE L ET ON -C A N INAEN D FE LIN E
A P P E NDI C U L AR

40. Hedhammar A, Olsson S E, Andersson S-A, et al: Canine hip dysplasia: Study of 71. Bennett D, Nash AS: Feline immune-based polyarthritis: A study of thirty-one
heritability in 401 litters of German shepherd dogs. J Am Vet Med Assoc 174:L012, cases.I Small Anin Pract 29:501,1988.
1979.
72. Cantwell HD: Radiographicdiagnosis.Vet Radiol 27:149,1986.
41. Leighton EA, Smith GK, McNeil M, et al: Heritability of the distraction index in
73. Kusba lK, Lipowitz AJ, Wize M, et al: Suspectedvillonodular synovitis in a dog. I
German Shepherd dogs and Labrador Retrievers labstract]. Proceedingsofthe Ameri-
Am Vet Med Assoc 182:390,1983.
can Kennel Club Conference on Molecular Genetics and Genetic Health, 1994.
74. Somer T, Sittnikow K, Henriksson K, et al: Pigmented villonodular slnovitis and
42. Lust G, Rendano VT, Summers BA: Canine hip dysplasia:ConcePts and diagnosis.
plasmacltoid lymphoma in a dog. I Am Vet Med Assoc 197:877, 1990.
J Am Vet Med Assoc 187:638,1985.
75. Marti JN: Bilateral pigmented villonodular synovitis in a dog. I Small Anim Pract
43. Hedhammar A, Wu F-M, Krook L, et al: Overnutrition and skeletal disease.
381256,1997.
Cornell Vet 64:9, 1974.
76. Hanson lA: Radiographic diagnosis-carpal villonodular qnovitis. Vet Radiol
44. Lust G, Beilman WT, Dueland R, et al: Intra-articular volume and hip joint
Ultrasound 39:15, 1998.
instability in dogs with hip dysplasia. J Bone loint Surg (Am) 62:576, 1980.
77. Flo GL, Stickle RL, Dunstan RW: Sl.novial chondrometaplasia in five dogs. J Am
45. Lust G, Beilman Wl Rendano VT: A relationship between degree of laxity and
Vet Med Assoc 191:1477,1987.
slnovial fluid volume in coxofemoral joints of dogs predisposed for hip dysplasia.Am
I Vet Res4l:55. 1980. 78. Hubler M, Johnson KA, Burling RT, et al: Lesions resembling osteochondromatosis
in two cats.J Small Anim Pract 27:181,1986.
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
mucopolysaccharidosis type VI colony cause three different phenot)?es. J CIin Invest
47. Keller GG, Reed AL, Lattimer JC, et al: Hip dysplasia:A feline population study.
101:109,1998.
Vet Radiol Ultrasound 40:460, 1999.
80. Vail DM, Powers BE, Getzy DM, et al: Evaluation of prognostic factors for dogs
48. Root CR, Sande RD, Pfleuger S, et al: A diseaseof Maine Coon cats resembling
with synovialsarcoma:36 cases(1986-1991).J Am Vet Med Assoc 205:1300,1994.
congenital canine hip dysplasia. Proceedings of the Annual Meeting of the American
College of Veterinary Radiologists, 1987, Chicago. 81. Silva-Krott IU: Synovial sarcoma in a cat. J Am Vet Med Assoc 203:1430, 1993.

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.
diseaseand hip joint laxity by use of distraction index and Norberg angle measure- J Small Anim Pract 29;139,1988.
ments in a group of cats. J Am Vet Med Assoc 213: 1439, 1998.
83. \\.tritelock RG, Dyce J, Houlton JEF,et al: A review of 30 tumours affecting joints.
50. Smith GK, Biery DN, Gregor TP: New concepts of coxofemoral joint stability and Vet Comp Orthop Traumatol 10:146,1997.
the development of a clinical stress radiographic method for quantitating hip .joint
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
evaluation of coxofemoral.joint laxity in dogs. Vet Surg 28:1, 1999.

56. Salter RB, Harris WR: Injuries involving the epiphyseal plate. I Bone loint Surg
45:587, 1963.

57. Farrow CS: Stress radiography: Applications in small animal practice. J Am Vet
Med Assoc I8I:777, 1982.

58. Puglisi TA, Tangner CH, Green RW, et al: Stress radiography of the canine
humeral joint. J Am Anim Hosp Assoc24:235,1988.

59. Bellah lR, Weigel lP: Hemarthrosis secondary to suspectedwarfarin toxicosis in a

dog. I Am Vet Med Assoc 182:1126,1983.

60. Hoaglund FT: Experimental haemarthrosis: The response of canine knees to

injection of autogenous blood. J Bone Joint Surg 49:285, 1967.

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.

66. PedersenNC, Pool RR, O'Brien T: Feline chronic progressive polyarthritis. Am J

Vet Res41:522,1980.

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-

69. Bennett D: Immune-based non-erosive inflammatory joint disease of the dog: I.

Canine SLE. J Small Anim Pract 28;871,1987.

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.

4. List three types of stressthat can be applied to a joint during

stressradiography.

5. Name the primary joint neoplasm.List three other neoplasms

that can appear radiographically similar to it. Figure 16-34

6. rrVhat concentration and volume of contrast medium wouid

you select for shoulder arthrography of a juvenile Labrador re-
triever with suspectedOCD of the humeral head?
7. List the origin of intra-articular calcified bodies that may be
seen in the canine elbow.
8. An l8-month-old Beagle sustained carpal trauma. Look at
Figtre l6-32-a dorsopalmarcarpal radiograph. Describethe pa-
thology evident on this radiograph. What could be done to further
evaluatethe joint (other than taking the lateromedial, and possibly
oblique, views)?
of an lS-month-old Labrador retriever to assessfor hip dysplasia.
Look at Figure 16-33. Are there any radiographic signs of hip
dysplasia?What are they? What else could be done to further
evaluate the coxofemoral joints?
10. The shoulderof an 8-year-oldBoxerwas radiographedbecause
of lameness.Look at Figure 16-34. What are the likely causesof
the changesseenin this radiograph?
Chapter 16 questions courtesy ofAlice Springs Veterinary Hospital, Alice
Springs, Australia.

9. An extended ventrodorsal radiograph was made of the pelvis Answers begin on page 727.
 APPENDICULAR
SKELETON-EOUINE
ffi CHAPTER
A-,
ffi
ffi lnterpretation Paradigms for the
ffi .Appendicular
r
Skeleton-fquine
.
ffi C[fford R. Berry
Berry Nancv
Nancy E. Love
The approach to interpretation of large animal radiographs is
essentially the same as that for a small animal patient. Primary
differences between large and small animal radiography are dis-
cussedin this chapter. However, the reader is encouragedto review
Chapter 72 for materral presented there on bone formation and
types of bone responseto diseaseamong small animals. These
same responsesare relative to large animals with the exception that
differential diagnostic lists are typically not as extensive.Entities in
horsescommonly resuiting in skeletalradiographic changesinclude
acute injury, chronic repetitive trauma, degenerativejoint disease,
infection, iatrogenic and metabolic derangement, and, rarely, im-
mune-mediatedor neoplasticdisorders.'
Routine radiology is a standard of practice for the evaluation of
many equine orthopedic conditions.'-nRoutine radiographs are
used in evaluation of the skull, larynx/pharprx, thorax, and abdo-
men.1Emphasishas been placedon obtaining correct diagnosesas
well as on identifring how a particular diseaseresponds to therapy.
Determining both the extent of a lesion and the involvement of
adjacentsoft tissueand bone is an important aspectof the radio-
graphic examination. Additionally, the call for multiple joint exami-
nations within a pre-purchaseexamination has increasedin fre-
quency. These factors, along with the unfortunate litigious nature
of our society,emphasizethe importance not only of proper radio-
graphic technique but also of accurate methods of evaluation and
interpretation of standard radiographic projections of the equine
musculoskeletalsystem.
I Technical considerations
Accurate radiographic evaluation of equine skeletal disorders re-
quires precisetechnique,positioning, and development,along with
a systematicapproach to radiographic review and interpretation.I-6
The radiographermust possessexpertisefor proper positioning of
the standing horse relative to the primary x-ray beam for various
radiographic projections.TOwing to the complexity of equine
joints, routine radiographstypically include a lateromedial,a dor-
sopalmar (plantar), and two oblique (dorsolateral-palmarofplan-
taro] medial and dorsomedial-palmaro lplantarol lateral) radio-
graphs of joints distal to and including the carpus and tarsus.l'2
For the best radiographic detail, the radiographer should use the
slowest film-screen combination consistent with the capabilities
of the x-ray machine. Low-output portable x-ray machines are
Donald E. Thrall
satisfactory for distal limb radiographs but are problematic for
evaluation of the upper limb, neck, or trunk. Additional safety
considerationsare also important.s Routine use of lead gloves,
aprons, lead thyroid shields, lead-impregnated glasses,and cassette
holders is a necessaryradiation protection measure. Proper re-
straint of the horse using tranquilization as necessary,to minimize
the number of people involved, and proper collimation are other
radiation safety factors to consider. Other technical procedures that
are an important part of patient preparation include the removal
of horseshoes, proper foot cleaning,and packing of the lateral sulci
of the frog prior to radiographic evaluation of the distal extremity.6
Labeling of radiographs should be done in a systematic and
meticuious fashion. One should place the right/left marker on the
lateral side of the horse's limb for the dorsopalmar (plantar) and
oblique radiographs. Also, the right/left marker should be placed
on the dorsal aspect of the limb for lateromedial radiographs.
From the midmetacarpus and midmetatarsus distal1y,the lateral
and medial aspectsof the limb are axially symmetrical; therefore,
lateral and medial cannot be differentiated on radiographs that do
not contain a marking system.As part of the developmentprocess,
film labeling with proper animal and owner identification as well
as the date of the study should be provided.
Prior to review of the study for abnormalities, the radiographs
should be assessedfor quality and positioning. Identification of
problems may mean a second or even a third trip to the farm for
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
of the joint or area in question.Follow-up radiographicevaluation
of certain joints may require additional radiographs at a slightly
different angle of the limb to ensure that abnormalities have been
projected tangent to the primary x-ruy beam. Follow-up radio-
graphs may include evaluation of the other limb, as developmental
variants are typically bilaterally symmetrical.
Portablefluoroscopicunits should not supplantthe radiographic
study of a given joint. A negative fluoroscopic study does not
equate with a normal radiographic evaluation of the particular
area in question. The contrast and spatial resolution of routine
radiographs are superior to images obtained during fluoroscopic
examination. Additionally, the potential radiation burden received
by the operator of the fluoroscopic unit and others involved has
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

Review of the radiographs should be done in a quiet, dark area

with an available "hot" light. Typically, radiographs with a short
scale of contrast result in loss of normal soft tissueswhen normal
viewing box luminescenceis used, and each radiograph should be
reviewed using the hot light. As with other studies, a specific order
should be followed for review when the radiographs are hung or
placed on the viewer. Tracing each bone and evaluating al1 of the
musculoskeletalstructures will help to ensure that the interpreter
is not missing a particular lesion or radiographic abnormality.
When the radiographs are hung, a standard pattern may include
placing the dorsopalmar (plantar) view on the radiographer's left,
then the lateromedial, flexed lateromediai, and trvo oblique radio-
graphs, and any special oblique or skyline projections. This simple
pattern will allow one to take a step back and get an overview of the
radiographs (seeChapter 5). If multiple joints are to be reviewed, it
is best to concentrate on only one joint at a time. The brain can
processonly a certain amount of information simultaneously, and
it is better to completely review one joint than to get overwhelmed
by reviewing radiographs of multiple joints simultaneously' Once
an interpretation is rendered on a given joint, the radiographs
should be removed from the viewer and the next joint reviewed.
Making notes or providing voice dictation of findings for each
ioint will facilitate summarizing of all identified abnormalities.

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
apparent than in similar small-animal non-weight-bearing radio-
graphic studies.
The location of the lesion in the bone is as imoortant in horses
as in sma1lanimals.Traumatic injury to bone. periosteum,or soft
tissues can occur at any location in the bone, so complete evalua-
tion of each radiograph is necessary.Epiphyseal disorders usually
include disorders specific to the growing horse, or to degenerative
joint disease.Physeal and metaphyseal disorders include angular
limb deformities, growth-related abnormalities (aseptic physitis),
septic bacterial emboli with physeal and metaphysealosteomyeiitis,
and trauma (fracture).Diaphysealdisorderstend to be confined to
traumatic injuries (e.g.,stressfractures,fractures).
I Interpretation
I paradigm-equine
I musculoskeletal radiology
Within each of the chapters related to specific areas of the equine
limb, the radiographic abnormalities of commonly encountered
disorders are described. Use of a standardized evaluation system
for hanging and reviewing radiographs is imperative. Once the
radiographs have been placed on the viewbox in a systematic
fashion, an overview of the radiographs can be made. Each radio-
graph should be removed sequentiallyfrom the viewbox and exam-
ined using a hot light. Soft tissuesshould be evaluatedfor swelling
or loss of normal/expected soft-tissue/fat planes. Next, the align-
ment of the bones relative to each other should be reviewed, as
well as the alignment of the bone itsell while note is made of
subluxation, luxation, or cortical changes.When alignment is eval-
uated, it is important that the bones themselvesare in their ex-
pected location and have a typical shape for the age of the horse.
The cuboidal bones of the carpus and tarsus often have incomplete
ossification and an incomplete shapein the neonatal foal compared
with the adult.'' " Areas of soft-tissueswelling (even if minimal)
should be critically reviewed for underlying periosteal or endosteal
reactions or cortical disruption. The intramedullary cavity must be
scrutinized for areas of osteosclerosisor osteolysis.The overall
cortical thickness in the foal and weanlins is thinner than in the
adult, but it alsohas a less"compact" appeirance.More prominent
cancellous trabecular patterns are seen in the epiphyseal and me-
taphyseal regions of the younger horse when compared with the
adult. Finally, the joint margins, the articular cartilage-subchondral
bone interface, and the joint space thickness should be evaluated
for radiographic evidence of increasedor decreasedwidth.
Expected variations in normal bone configuration are similar to
those listed in Chapter 12. Anticipated radiolucencies within the
bone include the physis and the nutrient canal. Certain areas,
especially in the distai phalanx and in the proximal and distal
sesamoidbones, have conspicuous vascular channelsthat represent
normal changeswithin the bone. The pattern of vascularchannel
development in the distal phalanx is variable between breeds of
horses and even over the life of an individual horse.'' tt These
vascular channels can also change in size and number in various
diseasessuch as laminitis or pedal osteitis.l3Radiolucentsprovial
invaginationsin the distal border of the distal sesamoidbone are
anticipatedin all horses.'5Radiolucentchannelsalong the abaxial
margin of the proximal sesamoidbones are causedby blood vessels
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-
nosed as a fracture.6Re-imagingthe foot after proper packing and
noting that the radiolucent line extends beyond the edge of the
distal phalanx are ways to know that the radiolucent line is not
a fracture.
When a horse does not bear weight on a limb, a very dramatic
disuseosteopeniawith decreasedoverali bone opacity occurs within
severalweeks. The osteopenia may be severeenough to warrant a
P aradi gms
for the A ppendi cul ar
S kel eton - Equine 2ll
reduction in radiographic exposurefactors to avoid overpenetration
of the bone.
The chestnut and ergot result in radiopacities superimposedover
the metatarsus, the antebrachium, and the metacarpo-/metatarso-
phalangealjoints, respectively.Miscellaneousdebris on the skin can
also create artifacts superimposed over underlying bone that need
to be correctly identified as artifactual.
The normal bone respondsto diseaseby destruction (osteolysis)
or proliferation (osteosclerosis). The normal balancebetweenpro-
duction and destruction is maintained on a daily basis as osteonal
units are removed and replaced. In horses, particularly neonates,
osteolysis will supersede osteoproliferation in inflammatory dis-
eases,particularly hematogenousosteomyelitis or septic arthritis. A
moth-eaten or permeative appearanceto the bone may be present
without adjacent areas of osteosclerosis.This helps differentiate
benign lesions such as a subchondral cyst with surrounding sclero-
sis from osteolytic lesions of the subchondral bone secondary to
septicarthritis (Fig. 17-3). Dramatic osteolyticlesionscan develop
within 24 to 48 hours in foals with hematogenous osteomyelitis
(Fig. l7-a).
The bone responsein the neonate has a lamellar appearance,
and in the adult, new bone proliferation (periosteal) appearsmore
spiculated or smooth. Subperiostealhematomas can mineralize and
also appear as focal smooth bone exostosesalong a diaphyseal
cortex. It is important to remember that the responseof the bone
is dependent on many factors and that there is a continuum
betweenthe appearanceofan aggressive lesion and that ofa benign
lesion. It is also important to remember that bone reactions take
time to develop, even after a penetrating wound has occurred. An
acute bursal infection of the distal sesamoid bone or acute seotic
arthritis may not initially have any radiographic evidence of bone
cnange,
For radiographic evaluation, one should remember to use roent-
gen signs as the tools to describe the abnormality. This assumesa
working knowledge of normal radiographic anatomy and possible
normal anatomic variations. Additionally, the astute equine prac-
titioner memorizes the specific "go to" areason the radiograph for
specific diseaseprocesses.These areas are not meant to limit the
extent of the radiographic examination. For example, one should
not fall into a false senseof security that there cannot be anything
else wrong with the tarsus just becausetypicai areas of the tarsus
have been evaluatedfor osteochondrosis.This type of searcherror,
that is, stopping too soon, is a common mistale and should be
avoided. Using the hot light for evaluating each radiograph forces
the interpreter to look at each radiograph individually and to focus
on specificareas.
Once radiographic abnormalities have been detected and de-
scribed, one can proceed to compile a reasonabledifferential diag-
nostic list, or a specific diagnosis based on the abnormalities
present, signalment, clinical history, and presentation. When all
facts are tied togetheq there are several caveats.The first is that a
normal radiographic study does not equate with the absence of
bone abnormalities. Thirty percent to 50o/oof the total bone mass
must change before a lesion can be detected radiographically. Sec-
ond, radiographic abnormalities may or may not correlate with
clinical lamenessor the absenceof lameness.Finally,further diag-
nostic testing should include nerve blocks and nuclear medicine (if
available) if multiple radiographic lesions are identified.
I Alternate imaging
Alternate imaging techniques availablefor evaluation of the equine
musculoskeletalsystem include computed tomography, ultrasonog-
raphy, magnetic resonanceimaging, and nuclear medicine.
Computed tomography requires specialized adaptations to the
patient table so that table motion can still be achieved while the
weight of an adult horse is supported.Computed tomography has
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 174. Dorsopalmarradiographof the right metacarpophalangeal joint. Thereare dramatic

a r e asof osteol ysiw
s i thoutsurroundi ng
boneproducti on, w hi ch i s i ndi cati ve
of an aggr es s i vlees i on.
T h e s echangesrepresenthematogenous osteomyel i ti s,
and they devel opedover a 48 -hourperi od
oI 7ime.Pseudomonasand Klebsiellaspecieswere isoiated.
 l nterpretati on
P aradi gms
for the A ppendi cul ar
S kel eton- Eouine 2lg

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
tomography has also been used to evaluateequine skull abnormali-
ties and lesions of the distal extremities and cranial cervical soine
(Fig. 17-5). Limitation as to what body parts can be imaged is
determinedby the gantry bore size.17 20
Ultrasound has been a mainstay in the evaluation of ligament
and tendon injuries in the racing and working equinepopulation.r0
Initial lesion localization, description, and architecture are well
visualized with ultrasound imaging. Evaluation of the pattern of
fiber replacementand realignmentcan be accomplishedwith ultra-
sound imaging. Other areas (aside from palmar metacarpal or
metatarsal imaging) that have been evaluated using ultrasound
include the bicipital tendon, the Achilles tendon, thi tarsal liea-
ments, and the stifle joint. Ultrasound can be used to evaluite
articular cartilage erosions of the tarsus and stifle, particularly in
the neonatalfoal. SeeChapter 21 for examplesofultiasonographic
imaging of tendons.
Magnetic resonanceimaging is becoming more available for
assessment ofthe horse.Becauseofthe exquisitecontrastresolution
of MR imaging, there is great potential for its use in assessing
conditions such as navicular syndrome, in which inflammation and
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
not detectablewith other imaging modalities.'o'" A major limita-
tion to the use of MR imaging has been the relatively inaccessible
magnet bore; however, new open magnets are now available that
allow imaging of equine iimbs and head.
Nucleai medicine is an effective method of rapid screening for
areasof increasedor decreasedbone metabolic activity.tt The classic
injury identified by nuclear medicine is the acute stress fracture-
related injury, or increased bone activity secondary to repetitive
trauma.23Additional soft-tissue inflammatory changescan be im-
aged when a soft-tissue phase of the ee'Tc-methylene diphospho-
nate study is used, or when a ee*Tc-pertechnetateor diethylenetria-
mine penta-acetate(DTPA) study is undertaken to assessfor
inflammatory changes specific to the soft tissues of the area in
question. One area for which the soft-tissue phase of the nuclear
medicine study has proved to be effective is the evaluation of soft
tissuessurrounding the distal sesamoidbone (Fig. 17-6). A positive
soft-tissue study for this region is consistent with inflammatory
changeswithin and around the distal sesamoidbone.'o
I Summary
Equine radiography is challenging owing to the technical limita-
tions of portable equipment, the frequent use of this equipment in
the field, and the complex anatomy that must be imaged using
multiple radiographs. Routine radiography of the equine limb
requiies patience and some level of expertise in obtaining and
intirpreting the radiographic study. The basic principles laid out
in this chapter,along with those found in the other chaptersrelated
to equine joints, provide the initial framework on which to build.
References
1. Butler JA, Colles CM, Dyson SJ, et al: Clinical Radiology of the Horse. London,
Blackwell Scientific Publications, 1993.
2. Shelley J, Dyson S: InterPreting radiographs 5: Radiology of the equine hock'
Equine Vet l 16;488,1984.
3. Park RD; Radiographic examination of the equine foot. Vet Clin North Am
Equine Pract 5:47, 1989.
4. Rendano VT, Grant B: The equine third phalanx Its radiographic appearance J
Am Soc Vet Radiol 19:125,i978.
5. Koblik PD, Toal R: Portable veterinary x-ray supPort systems for field use J Am
Vet Med Assoc 199:186,1991.
6. Starrak GS: Radiology corner: Equine foot PreParalion. Vet Radiol Ultrasound
37:116,1996.
7. Koblik PD, O'Brien TR, Cope CP: Effect of dorsopalmar proiection obliquity on
radiographic measurement of distal phalangeal rotation in horses with laminitis J Am
Vet Med Assoc 192:346,1988.
8. Thomas HL, Trout DR, Dobson H, McFadden RC: Radiation exPosureto person-
nel during examination of limbs of horses with a portable hand-held fluoroscopic
unit. I Am Vet Med Assoc 215:372,1999.
9. Kneller SK, Losonsky JM: Variable locations of nutrient foramina of the proximal
phalau in forelimbs ofThoroughbreds. J Am Vet Med Assoc 197:736,1990.
10. Kneller SK, Losonsky JM: Misdiagnosis in normal radiographic anatomy: Nine
structural configurations simulating disease entities in horses. I Am Vet Med Assoc
195:1272,1989.
ll. Farrow CS; Critical thinking: Radiographic misdiagnoses in horses. Can Vet I
36:442,1995.
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.
13. Linford RL, O'Brien TR, Trout DR: Qualitative and morphometric radiographic
findings in the distal phalanx and digital soft tissues of sound Thoroughbred race-
horses. Am J Vet Res 54;38, 1993.
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
weanling, young and adult horses. Equine Vet J 23:413' 1991.
15. Poulos P: The nature of enlarged "vasculat channels" in the navicular bone of the
horse.Vet Radiol 29:60, 1988.
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.
17. Ramirez O, lorgensen ]S, Thrall DE: Imaging basilar skull fractures in the horse:
A review.Vet Radiol Ultrasound 39:391,1998.
18. Riggs CM, \ /hitehouse GH, Boyde A: Structural variation of the distal condyles
of the third metacarpal and third metatarsal bones in the horse. Equine Vet I
3l :130,1999.
19. Crass lR, Genovese RL, Render JA, Bellon EM: Magnetic resonance)ultrasound
and histopathologic correlation of acute and healing equine tendon injuries. Vet Radiol
Ultrasound 33:2O6,1992.
20. Widmer WR, Buckwalter KA, Fessler )F, et al: Use of radiography, computed
tomography and magnetic resonanceinaging for evaluation of navicular syndrome in
the horse.Vet Radiol Ultrasound 4l:108, 2000.
21. Koblik PD, Freeman DM; Short echo time magnetic resonanceimaging of tendon.
Invest Radiol 28:1095, 1993.
22. Hoskinson Jj, Tucker RL, Lillich J, Bertone Jl: Advanced diagnostic imaging
modalities available at the referral center. Vet Clin North Am Equine Pract 13:601,
1997.
23. Ruggles A], Moore RM, Bertone AL, et al: Tibial stress Iiactures in racing Stan-
dardbreds:13 cases(1989-1993).I Am Vet Med Assoc 209:634,1996.
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.
W Ouestions
1. The oosition and orientation of the nutrient foramen are most
variable in which bone of the eauine?
A. Proximal phalanx
B. Radius
C. McIII
D. Tibia
2. Radiation safety features used in equine radiology should in-
clude:
A. 0.5 mm Pb equivalent aprons, thyroid shields, and gloves.
B. Appropriate film-screen combinations for maximizing mAs
techniques.
C. Use of handheld cassetteextension devices.
D. Portable cradle systemsfor the portable x-ray equipment.
E. Film badgesand monitoring devicesfor all personnel in-
volved in making the x-rays.
F. All of the above
G. None of the above
3. Early septic arthritis is difficult to diagnose radiographically
becauseof:
A. Incompleteossificationof the subchondralbone.
B. Lack of appropriate radiographic techniquesto capture
early changesin the bone.
C. Septic arthritis not involving the bone.
D. None of the above
4. Normal anatomic variable developmentof the equine carpus
includes all of the following except:
A. Subchondral cysts of the radial carpal bone.
B. Ulnar remnant along the caudal and lateral aspectsof the
distal radius.
C. Incomplete ossification between the distal radius and the
lateral styloid processof the ulna.
D. Remnant of the first carpal bone.
5. An important anatomic difference in the blood vesselsbetween
smal1and large animais is that:
A. Metaphysealblood vesselsare connected to the diaphyseal
vessels.
B. Periostealblood vesselsare the primary blood supply to the
outer one third of the diaphysealcortex.
C. Metaphysealblood vesselloops cross the physis in the cow
and horse.
D. Epiphyseal blood vesselsin the dog are derived from the
metaDhvsealarterial arcade.

6. Diaphyseal disorders of the equine tend to be primarily re-
lated to:
A. Infectiousetiologies.
B. Traumatic injuries.
C. Metabolic disorders.
D. Endocrinopathies.
7. Normal radiolucenciesseenin the distal sesamoid(navicular)
bone of the horse are called:
A. Vascular channels.
B. Nutrient foramina.
C. Synovial invaginations.
D. Incomplete ossification.
8. Computed tomography can be used for evaluation of the horse
for each of the following abnormalities, except:
A. Comminuted proximal phalanx fracture.
B. Ethmoid hematoma.
CHA P T E R
1B
The Stifle
I Mary B. Mahaffev
f The stifle
Normal anatomy
The stifle is the largestjoint in the body. It consistsofthree separate
articulations: the femoropatellar, medial, and lateral femorotibial
articulations. The femoropatellar articulation is formed between
the trochlea of the femur and the articular surfaceof the oatella.
The femoral trochlea consists of two oblique ridges with a deep
groove between them; the medial ridge is much larger than the
lateral ridge (Fig. 18-1). Becauseof the large size of the medial
trochlear ridge, the patella lies lateral to the axis of the femur (see
Fig. 18*18). Besidesthe large medial trochlear ridge, there are
other landmarks that help differentiate the medial and lateral
aspectsof the femur on a lateromedial view. The extensor fossa for
the origin of the long digital extensor muscle is located on the
lateral aspect at the junction of the trochlear ridge and condyle
(seeFig. 18-1,4); the medial condyle is larger than the lateral onei,2
and has a "hook" that projectsproximally at the junction between
the condyle and the caudal aspectof the distal metaphysis (seeFig.
18-lA). The transition from the lateral condyle to the metaphysis
is smooth.
The femorotibial articulation is formed between the condyles of
the femurs and those of the tibiae with the interoosed menisci.
Between the condyles of the tibiae is a promineni intercondylar
eminence consisting of medial and lateral tubercles;the medial
tubercle extends farther proximally than the lateral tubercle. The
large medial tubercle of the intercondylar eminence of the tibia
is a useful landmark for distinguishing medial from lateral in
caudocranialradiographsof this joint, particularlyif the patellaand
fibula are not visible (see Fig. 18-18). The fibula is incompletely
mineralized. Radiolucent gaps between mineralized segments are
normal (Fig. 18-2) and must not be misinterpretedas fractures.3s
There are two ossification centers within the distal femur and
three in the proximal tibia that are radiographically visible in the
The Stifle 215
C. C6-7 articular facet osteochondrosis.
D. Third tarsal bone fracture.
9. Ultrasound has been used primarily for the evaluation of:
A. Multiple radiographic abnormalities noted on survey radio-
grapns.
B. Ligament and tendon injury of the suspensoryligament.
C. Comminuted tarsal bone fracture of the third tarsal bone.
D. The distal phalanx and dorsal hoof wa1l for laminitis.
10. Nuclear medicine has allowed for the evaluation of which oart
of the navicular syndrome?
A. Soft-tissue phase for the evaluation of navicular bursitis
B. Acutebone awlsion injuries
C. Proximal border enthesooathv
D. Increasedsize and ttr.t-b., of the distal sesamoidbone
n a v i c u l a ri n v a g i n a t i o n s .
Answers begin on page 727.
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
in the tibia. The cartilaginousjunction betweenthe tibial tuberosity
and the other two ossification centersof the tibia is often irresular.
The distal femoral physis closes radiographically at approximately
22 months.6 The tibial tuberosity unites with the proximal tibial
epiphysis at 9 to 12 months.5'7 Proximal tibial physeal closure
begins at 20 to 24 months and is usually complete by 30 to 36
months, with the distal aspect of the tibial tuberosity physis being
the last to close.s7 The fibula is incompletelv mineralized at birth
and may not be visible radiographicailyin young foals.3,7 The
femoral trochlea and patella are normally irregularly marginated in
foals younger than 5 months of age (see Fig. 18-38) owing to
incomplete ossificationof the cartilaginoustemplatesof those
structures.s'e The trochlear ridges are more irregularly marginated
proximally than distally. Care must be taken not to misinterpret
this change as evidence of septic arthritis. Conversely,the femoral
and tibial condyles of foals are always smoothly marginated, and
any irregular margination of these structures should be interpreted
as abnormal.8'e
Radiographic technique
For routine evaluation,caudocranialand lateromedialproiections
of the stifle should be made. Occasionally,craniolateral-caudome-
dial or caudolateral-craniomedial oblique views are useful to pro-
iect other surfacesof the joint. Raising and extending the hindlimb
caudally can be a useful technique to improve proximal positioning
of the cassettefor the lateromedial view.7 The stifle will tend to
move distally and to be partially flexed when this is done. A
cranioproximal-craniodistal oblique (skyline) view of the patella is
useful for evaluating the medial and lateral surfaces of that bone
(Fig. 1B-a), especiallywhen fracture is suspected.a,s,r0,rr
That view
is taken with the joint held in flexion. Becauseof the thickness of
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
primary beam so that it strikes the grid perpendicularly and the
necessityof large exposure factors.
Radiographic abnormalities
Osteochondrosis and osseous cyst-like lesions. Osteochon-
drosis is a relatively common disorder in young horses. It results
from cartilage maturation failure in which the proliferating carti-
lage model is not completely replaced by bone. The persistent
cartilage appears radiographically as a radiolucent bone defect,
which is usuallv adiacent to an articular surface.
In the equine stifle, osteochondrosismay affect the lateral troch-
lear ridge of the femur (Fig. 1B-5), in which instance the periphery
of the lateral trochlear ridge has an irregular appearanceowing to
multiple areas of cartilage that have not matured into bone.r2
Occasionally, free or partially detached osteochondral fragments
are observed adjacent to the periphery of the trochlea. Osteochon-
drosis is often bilateral; therefore, a radiograph of the opposite
stifle should be taken if osteochondrosisis identified.

Figure 18-2. Close-uplateralview of a normaladult equinestifle. Note the

radi ol ucent
l i nei n the fi bul a.Thi si s a normalfi ndi ngdue to separateos s i fi c ati on
centers;i t i s frequentl ymi si nterpreted as a l racture.Occasi onal l more
y, than
one radi ol ucent l i ne i s seen ow i nq to the oresenceof more than tw o os s i fi c a-
tl on centers.
 Th e St if le 217

r llu,rirtit:rutatii
:-
' :, - - 1 -
-:

e-- * -! *-..
F- .
i- *- r

,:-'"',

elrr,.
,
lt:llrli
tii6lt.,

:
, ' * * , , u'

Figure 18-3. A normal, immature equine stifle, ater-

omedialiAl, close-uplateromedial(B),and caudocranialiCl
views. Arrowheadpointsto the supracondylar fossa. Note
di stalfemoraland proxi malti bi al phvsesas w el l as the
apophysi of s the ti bi altuberosi ty.
A l so note the rrregul arity
of the patel l aand crani a aspectof the trochl ea/g/; thi s
normalappearance i s seeni n foas w ho are youngerthan5
monthsof age and shoul dnot be confusedw i th an aqqres -
si ve i esi on,suchas l nfecti on.
2 I8 S KE L ET ON -EOU IN E
A P P E NDI C U L AR

Bone "cysts" have been described as occurring in many locations

in horses.l3One location is the medial femoral condyle. In some
reports, it has been suggestedthat thesecystic lesions are a manifes-
tation of osteochondrosis;this conclusion is unproved. In addition,
there is debate as to whether these lesions are true cysts.Therefore,
it seemsprudent to refer to them as osseouscyst-like lesions.In
the stifle, these lesions are found primarily in the medial condyle
and may be observedin horsesof any age." Radiographically,these
cyst-like lesions appear as subchondral radiolucent defects (Figs.
18-6 and 18-7). Joint communicationmay be presenqradiographic
confirmation of such communication requires that the x-ray beam
strike the area of joint involvement tangentially (see Fig. 18-7).
Thus, even if joint communication is present,it may not be identi-
fied radiographically. These osseouscyst-like lesions are often bilat-
eral and, if one is identified, the opposite stifle should be radio-
graphed. Occasionally, osseous cyst-like lesions are found in the
Iateral condyle or the proximal tibia, but these locations are less
common sitesof occurrencewhen compared with the medial femo-
ral condyle.
Normal radiographic findings do not necessarilyrule out osteo-
chondrosis. In one study 40o/oof radiographically normal horses
and 78o/oof horses with mild flattening of the subchondral bone
had abnormai cartilageon arthroscopicexamination.ttUltrasound
examination can be useful to evaluate articular surfacesas well as
soft-tissuestructuressuch as ligamentsand menisci.to
Sepsrc. A common cause of stifle sepsis in foals is the occur-
rence of bacteremia as a result of umbilical infection. The radio-
graphic appearance of stifle osteomyelitis is similar to that of
Figure 184. Cranioproxima[craniodistal oblique(skyline)view of the stifle bone infection elsewherein the body; the resulting bone lesion is
of a n o r m a a d u l th o r s esh o win gth e a r ticu la tiobne twe e nth e p atel l aand the aggressive.There is usually soft-tissue swelling, which may reflect
l o ch le ab; , la te ralri dgeof the
f em o r a t r o c h l e aa. , m e d ia lr id g eo f th e fe m o r a tr cellulitis as well as joint effusion, and osteolytic lesions often
femoraltrochlea:arrowhead,articularsurfaceof the patela. occur in the femur, patella, and tibia (Fig. 18-B). If the infection

::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

Figure 18-7, Lateromedial/A/ and two caudocranial(8

a n d O r a d io g r a p hosf a n e q u in estfle . T h e r ei s a l argecyst-
like lesionin the medialfemoralcondyle(arrows).Articular
i n v olve m e nis t a p p a r e n tin o n ly o n e o f th e caudocrani al
radiographs(C); in B, the x-ray beam did not strike the
a r t i cu laco
r m p o n e no t f th e le sio nta n g e n tial l The
y. radi ol u-
c e n t r e g io n d
, ista lto th e m e d ia tu
l b e r cleo f the i ntercondy-
l a r e m in e n ceo f th e tib iain C is n o r m a la n d shoul dnot be
confusedwith a cyst-likelesion.

progresses,sclerosis reflecting new bone formation may be seen,
and an active periosteal reaction may develop.
Skin laceration or puncture, with subsequentbacterial contami-
nation, is another causeof septicstifle changesin horses.Changes
may be limited to the soft tissue, in which instance only soft-tissue
seen.If bone is involved, typical changesof osteomyelitis
:X."1*:."
Trauma. Tiaumatic alterations in the ecuine stifle should be
evaluated in the same manner as in the stifle joint of other ani-
mals.r6Fracturesof the tibial tuberosity,patella (Fig. 18-9), and
lateral trochlear ridge of the femur occur in decreasing order of
frequency.tTLigamentous damagecan often be evaluatedultrasono-
graphically.loDegenerativejoint diseasemay develop as a result of
external trauma or wear and tear. Sisns are identical to those seen
in degenerative joint diseasein otheijoints. including periarticular
osteophyteformation (Fig. 18-10), decreasedsize of articular
spaces,and subchondral osteolytic defectsdue to s1,novialhyperpla-
sia. Care must be taken in the evaluation of articular space size
becausethis determination is influenced by the geometric relation-
ship of the x-ray beam, the articular space,and the cassette.
Distal patellar changes. Fragmentation, enthesophyte forma-
tion, subchondrai irregularity, and radiolucency ofthe distal patella
have all been reported in adult horses with stifle lamenesi (Fig.
18-i1;.'r One of the potential causesfor thesechangesis instability
of and stresson the distal patella causedby medial patellar desmot-
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

Figure 18-9. Cranioproximal-craniodistal oblique (skyline)radiographof a

horsewith fractureof the craniomedial aspectof the patella.A bone fragment
(arrow)ts seen within the soft tissuesmedialto the patella,and the underlying
Figwe 18-8. Caudocranialradiographof the stifle of a foal with septic bone i s i rregul arlmargi
y nated.The l atterfi ndi ngi s suggesti v eof c hroni c i ty .
arthritisand femoralosteomyelitis.Thereis an aggressive,primarilyosteolytic These lesionswere not well identifiedon the mediolateral view.
les io ni n t h e m e d i a fl e m o r a co l n d yleIn . a d d itio nth, e r eis g a s in th e soft ti ssues
med i a lt o t h e m e d i a lf em o r a lco n d yle .T h is r a d io g r a p h ic a p p e arance of the
equi n es t i f l ei s v i r t u a l l yd ia g n o stic
fo r b a cte r iaol ste o m ye litis.

Figure 18-1O. The stifle of a horsewith degenerativejoint disease,lateromedial1Aland caudocranial

(8/ views. There is a largeperiarticular
osteophyteon the
of the medialmeniscus(arrowhead).
medialtibial condyle(arrow)andmineralization
 The Stifle 221

Tumoral calcinosis. Tumoral calcinosis (calcinosis circum-

scripta) may appear clinicaily as a hard nodule on the lateral aspect
of the stifle.2o''ZRadiographically, the nodule contains punclate
areasof mineralization (Fig. 1B-12).The causeof tumoral calcino-
sis is unknown; affected horses usually are not lame.

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.

ll. Marble GR Sullins KE: Arthroscopic removal ofpatellar fracture fragments in

horses:Five cases(1989-1998).J Am Vet Med Assoc 21i:1j99,200,.

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.

16. Sanders-Shamis M, Bukowiecki CR Biller DS: Cruciate and collateral ligament

failure in the equine stifle: Sevencases(1975-1985).J Am Vet Med Assoc 193:573,
1988.

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
B. 15
c. 40
D. 75
E. 90
3. Stifle joint infection most commonly occurs:
A. Following a kick bY a dam.
B. After intra-articular injection.
C. Secondaryto mastitis.
D. Secondaryto umbilical infection'
E. Secondaryto fistulous withers.
4. On radiographs of the normal foal stifle:
A. The fibula is usuallY identified.
B. The tibia has two major centers of ossification.
C. The margin of the patella is usually smooth and sharp'
D. The margitt of the femoral trochlea is usually irregular'
E. The marjins of the femoral condyles are normally irregular'
CHAPTER
1I
'he Tarsus
r Debra K. Baird
The equine tarsus is complex and reportedly is the most commonly
affected joint in horses with hindlimb lameness.l- The equine
tarsus comprises the talus and calcaneus as well as the central,
fused first and second, and third and fourth tarsal bones' The
calcaneus,the largest bone of the tarsus, includes the tuber calca-
neus, which deveLps as a separatecenter of ossification' Ossifica-
tion of the tuber .ulcat"ns proceedsin a dorsoproximal direction;
it fuses to the main part of the calcaneus between 16 and 24
months of age.t'u The ialus and the calcaneusform the proximal
row of bonei in the tarsus. The trochlear ridges of the talus are
distinct features of the bone. The lateral trochlear ridge can easily
be identified radiographically owing to the large notch at its distal
aspect. The medial trochlear ridge does not- have this distinctive
not.h bnt its distal asPect can exhibit variable appearances'The
variation in appearancecan range from a small protuberance to
separateorr.ooi opacities at its aistal end.t The fitst and second
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
radiographically separatefirst and second tarsal bones'6The lateral
malle"olusalso ilorms as a separatestructure that fuses to the tibia
in most foals by 100 days of age but may take up to 6 months'6
There are four synovial cavities, or joints, of the tarsus: tarso-
crural, proximal iniertarsal, distal intertarsal, and tarsometatarsal'
The tar-socrural joint is the largest synovial clyity a.nd.the one
involved in "bog spavin." It communicates dorsally with the proxi-
mal intertarsal foint. Usually, the distal intertarsal and tarsometa-
tarsal ioints are separate synovial cavities. In some horses, the
tarsociural and proximal intertarsal joints communicate with the
distal intertarsal joint.8 In approximately 9o/oof horses, the distal
intertarsal joint communicatei with the tarsometatarsaljoint' This
percentagecan be increasedro 24o/owith increasedinjection pres-
sure.n
I RadiograPhic technique
Use of a grid is not necessaryto obtain diagnostic radiographs of
the tarsus. However, accurate positioning is essentialowing to the
5. The most common location for osteochondrosisin the stifle is:
A. The patella.
B. The lateral tibial condyle.
C. The medial tibial condyle.
D. The medial trochlear ridge of the femur.
E. The lateral trochlear ridge of the femur.
6. True or False. Tumoral calcinosis in the stifle usually causes
lameness.
7. True or False.On the caudocranial view of the stifle, the patella
is lateral to the axis of the femur, and the medial tubercle of the
tibial intercondylar eminence is larger than the lateral tubercle.
8. True or False.On the lateromedial view of the stifle, the lateral
trochlear ridge of the femur projects farther cranially than the
medial trochlear ridge.
Answers begin on prge 727,
complexity of the joint. The rear limb should be positioned
squarely beneath the horse so that the metatarsus is perpendicular
to the ground in both the lateromedial and dorsoplantar directions'
A complete radiographic examination of the tarsus includes dor-
soplantar, lateromedial, dorsolateral-plantaromedial oblique, and
dorsomedial-plantarolateral oblique views. Additional views to en-
hance visualization of particular areas or bones are sometimes
needed. For example, a dorsoplantar view slightly obliqued in the
lateral direction (10 to i5 degrees)is beneficialwhen the medial
malleolus is evaluatedfor osteochondrosis.Similarly, a flexed later-
omedial view allows evaluation of the proximal aspects of the
trochlear ridges of the talus. A flexed plantaroproximal-plantarodis-
tal view of the calcaneusallows evaluation of the calcaneusand the
sustentaculum tali without superimposition of other bony struc-
tures.lo This view is also called a flexed dorsoplantar viewll and is
particularly helpful in evaluation of the tarsal groove.
I Radiographic abnormalities
Osteochondrosis
Osteochondrosis(OCD) of the tarsocrural ioint is common in
the horse.r2't3 Radiographically, osteochondrosismanifests itself in
several ways. It can appear as a separate osseous fragment, a
smooth or irregular radiolucent defect, flattening of the bone con-
tour, or an osseous cyst-like lesion. In the tarsocrural joint, the
cranial aspect of the intermediate ridge of the distal tibia is the
most commonly affectedsite. A cleavageline within the cranial part
of the intermediate ridge is visible and indicates an osteochondral
view best
fragment (Fig. 19-l). The dorsomedial-plantarolateral
demonstrates the abnormaiity. The fragment can usually be seen
on the lateromedial view as well. Occasionally,the osteochondral
fragment becomes dislodged and is subsequently crushed within
the tarsocrural joint. In these horses,a radiolucent defect is appar-
ent at the intermediate ridge of the distal tibia. Small pieces from
the crushed osteochondral fragment often gravitate distally and
 TheTarsus 223

tertarsal, and tarsometatarsalioints to an earlv onset of desenera-

tive joint disease.lT

Degenerative joint disease

Bone spavin is a lay term used to denote degenerativejoint disease
of the tarsus. Degenerativejoint diseaseof the tarsus is considered
to be the most common cause of clinical lamenessassociatedwith
the tarsus.rSThe diseaseoften occurs bilaterally. The distal intertar-
sal and tarsometatarsaljoints are most frequently involved. These
two joints can be affected alone or in combination. The disease
has an insidious onset and usually begins at the dorsomedial
aspect of the joint. Thus, the dorsolateral-plantaromedial oblique
projection of the tarsus is important to evaluate for early signs of
the disease.However, in a recent study of Icelandic horses, it was
found that the dorsomedial-plantarolateral oblique view was the
most sensitive in detecting tarsal degenerativejoint disease.teIn
Iceiandic horses, the diseaseappears to begin at the dorsolateral
aspectofthe distal intertarsal and tarsometatarsaljoints. Periarticu-
lar osteophl'te formation is the most prevalent radiographic finding
in tarsal degenerativejoint disease(Fig. 19-4; see also Fig. 19-1).
In advanced or severely affected joints, subchondral bone lysis,
narrowing of the joint space, and ankylosis of the foint can also
occur (Fig. 19-5). There is not always good correlation between
radiographic changesand degreeof lamenessin the horse.2oIntra-
articular anesthesiais helpful in determining the significanceof the
radiographic lesions.
Degenerativejoint diseasecan also affect the proximal intertarsal
joint and the tarsocrural joint, but lessfiequently. When the proxi-
mal intertarsal joint is involved, there can be distention of the
Figure 19-1. Osteochondrosis ridgeof the tibia.Dor-
of the intermediate tarsocrural joint becauseof the communication of these two joints.
somedial-plantarolateral
obliqueviewof the tarsusof a 2-year-oldWarmblood Degenerativejoint diseaseof the talocalcanealioint has also been
witha history
3elding jointeffusion.
of tarsocrural A cleavagelinevisibleat the teDorted.2r,22
ridgeof the distaltibia(arrowheads)
-:ermediate representsanosteochondral
-agmentat thissite(arrow).A smallosteophyte isalsopresentat ihe dorsolat-
e'alasoectof the proximalthirdmetatarsal bone.

into the proximal intertarsal joint. Fine, granular radiopacities may

be seen iust dorsal to the central tarsal bone in these horses.tn
The lateral and medial trochlear ridges of the talus are also
commonly affected by OCD. The lateral trochlear ridge of the
talus is the second most common site of OCD in the tarsus.l5
Osteochondral fragments, radiolucent defects,and flattening ofthe
rormal contour of the trochlear ridge or ridges are manifestations
of OCD involving the talus (Fig. 19-2). Other sites of OCD affect-
ng the tarsus include the medial and lateral malieoli of the tibia.
Osteochondrosisof the medial malleolus is sometimes difficult to
detect on suffey radiographs, especially if an osteochondral frag-
:nent is not present. A slightly obliqued view (dorsal, 10 to 15
degreeslateral plantaromedial) provides better visualization of the
,:-rial border of the medial malleolus (Fig. 19-3). In some horses,
fre axial border appearsmore radiolucent or irregular than normal.
In tiese instances,the slightly oblique dorsoplantar view and xero-
:adiography may aid in visualization of a lesion at this site. If
:adiographic evidenceof OCD is found in one tarsus,the contralat-
eral tarsus should always be radiographed because the diseaseis
.rtten bilateral.
Osseousryst-like lesions, another manifestation of OCD, may be
.een in the distal tibia, the proximal third metatarsal bone, or any
of the tarsal bones. The occurrence of cystlike lesions in the tarsus
r-i much less frequent than in other joints (femorotibial, carpal,
netacarpophalangeal,metatarsophalangeal,interphalangeal).'uThe
,.i,zeof the cyst-like lesion and its proximity to an articular surface
.:suallv dictate its clinical significance. Osteochondrosis has also Figure 19-2- Osteochondrosisof the lateraltrochlearridge of the talus.
linked to juvenile degenerativejoint diseasein horses.tTIn Lateromedialview of the tarsus in a z-yealold Thoroughbred.The filly had
-en study, various OCD-related lesions were seen involving the been in trainingfor 2 weeks beforedevelopinga iarsocruraljoint effusion.The
ris dorsalborderof the distal lateraltrochlearridge of the talus appearsirregular
--arsalbones, including small subchondral osseouscyst-like lesions. and multiple osseousfragments are present (arrows).The small "beak-like"
These lesions may predispose the proximal intertarsal, distal in- protuberanceof the distalmedialtrochlearridge is a normalvariation.
 224 A P P E NDI C U L ASK
R EL E T O N -EOU IN E

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 .

Tarsal bone collapse

Tarsal bone collapse is a condition that is most common in twins
or premature foals. However, it can also be seen in older foals or
young adults. In some horses,tarsal bone collapsemay go unrecog-
nized until the horse is put to work and the joint is stressed.Tarsal
bone collapse has been described as a form of osteochondrosis.23
The terms ayascular and asepticnecrosishave also been used.raThe
condition has been linked to hlpothyroidism due to congenital
goiter, which leads to defective ossification of the tarsal bones.2s,26
Although the exact etiology of the condition is unknown, it is
thought to be related to skeletal immaturity at birth.27 Neonatal
prematurity, immaturity, or dysmaturity are predisposing factors.28
The end result is a marked compression-type fracture of the third
or central tarsal bones, or both, that exhibits a wedge-shaped
appearanceon radiographs (Fig. 19-6). Evidence of secondary
degenerativejoint diseasecan be present as well. In foals, tarsal
bone collapse is often associatedwith angular limb deformity. It is
not known whether the angular limb deformity promotes tarsal
bone collapse or the abnormality of the tarsal bone induces the
angular limb deformity. Tarsal bone collapse is often bilateral;
therefore, the contralateral joint should be radiographed.
A classification system describing the amount of collapse in the
central or third tarsal bones or both has been reported. A qpe I
iesion results when there is less than 307o collapse of the bone; a
type II lesion is caused by collapse of greater than 30% of the
bone. In a retrospective study, the severity of tarsal bone collapse
appeared to be associatedwith the athletic performance of the Figure 19-5. Degenerative loint diseaseof the tarsus.Dorsolateral-plantaro_
medial view of the tarsus in a 7-year-oldAppaloosawith a chronic hindlimb
horse. Foals with type II lesions were lesslikely to perform in their lameness.There is lysis of the subchondralbone involvinqthe dorsomedial
intended use.'?e aspeclof the distal,nrerta.sarpitl (arrows).
 TheTarsus 22|5

Figure 19-6. Third tarsal bone collapse.Lateromedialview of the tarsus in a 4-year-old

Sta n d a r d b r e dT.h e d o r sa lp a r t o f th e th ir d ta r sa lb o n e is we dge-shaped. Thi s radi ographi c
ap p e a r a n c ies t y p i c a lfo r a p r e vio u sco m p r e ssio nfr a ctu r ein thi s bone that i s predi sposed
ow i n gt o s k e l e t ailm ma tu r itya t b ir th .

Fracture
Fractureof the tarsus can be induced by a single,traumatic event,
or by repetitive stress-q?e injuries. Direct trauma to the tarsus has
reportedly resulted in fracture of the distal tibia and of each of the
tarsal and metatarsal bones.30The traumatic events included falls,
kicks from other horses,polo incidents, automobile encounters,
and racing accidents. Thrsal bone slab fractures occur in horses
working at racing speed,most frequently in Standardbredhorses.3,
Articular fractures of the dorsal aspectof the proximal third meta-
tarsal bone have been reported in Standardbredracehorses.32'33
Detection of fractures is sometimes difficult owinq to the complex
anatomyof the tarsus.This is especiallytrue of slab fracturesof
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
Figure 19-8. Osteomyelitis. Dorsal4s-degree radio-
lateral-plantaromedial
graphof the left tarsusfrom a 3-week-old Thoroughbredfoal. Thereare
multipleareasof bonelyslswithoutsurrounding reaction.
Thesechanges
involvethe centralandthirdtarsalbones,the calcaneous, the talus,tfreme-
taphysis,andthe epiphysis coliwas cultured
of the distaltibia.Escherichia
fromthejoint.
helpful, at which time a fracture line may appear more prominent
becauseof normal osteoclasticprocesses.When a fracture is sus-
pected, additional radiographic views may be beneficial in assess-
ment. The flexed lateromedial view of the tarsus is especiallyhelpful
to enhance visualization of the proximal aspect of the trochlear
ridges of the talus. In suspectedsustentacuium tali fractures, the
flexed plantaroproximal-plantarodistal view of the calcaneusis val-
uable.
Osteomyelitis
As with any other osseousstructure, osteomyelitis of the tarsus can
occur. The calcaneusis the most commonly involved tarsal bone.
Osteomyelitis of the sustentaculum tali has been associatedwith
unilateral distention of the tarsal sheath.3aThe tuber calcaneusis
prone to traumatic injury and subsequent infection. Frequently,
the horse presents with a draining tract over the plantar aspect of
the calcaneus.35 Radiographic lesions include soft-tissue swelling,
osteolysis,periosteal proliferation, bone fragments, sequestra,and
mineralization of soft-tissue structures. The plantarolateral-dor-
somedial oblique and flexed plantaroproximal-plantarodistal views
of the calcaneusare particularly helpful in demonstrating involve-
ment of the sustentaculum tali (Fig. 19-7). Sinography of the
draining tract, if present, may also be useful to show osseous
involvement.
Septic arthritis
Septic arthritis occurs most commonly in the foal and is often
accompanied by osteomyelitis. Septic arthritis may occur due to
hematogenousspread of microorganisms, from umbilical infection
or pneumonia, or by direct introduction into the joint from trauma
or joint injection, aspiration, or surgery. Hematogenous origin is
most common in foals, whereas direct trauma is a frequent cause
in older animals. The tarsocrural joint is most commonly affected,
and this results in joint distention. Slight lamenessmay be noted
early in the diseaseprocess, but it can quickly progress to non-
weight-bearing status. In foals, it is important that the distal tibial
physis/epiphysisand the central and third tarsal bones be carefully
examined for osteolltic areasthat indicate bone involvement (Fig.
19-8). Sequential radiographs are important for evaluating the
degree of bone destruction.
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
have associatedradiographic changes for several days or weeks.
Nuclear scintigraphy may identifi areasof increasedbone turnover
or blood supply earlier in these horses,before radiographic abnor-
malities become apparent.
References
1. McDonough j: Hock joint lameness.Am Vet Rev 43:629,1913.
2. Manning JP: Bone spavin.Illinois Vet 3:26,1964.
3. Vaughn lT: Analysis of lameness in the pelvic limb and selected cases.Proc Am
Assoc Equine Pruct IIt223, 1965.
4. Brokken TD: Tarsal lameness in Thoroughbreds: Diagnostic and prognostic aids.
Proc Am Assoc Equine Pract 24:341,1978.
5. Shively Ml, Smallwood lE: Radiographic and xeroradiographic anatomy of the
equine tarsus. Equire Pract 4:9, 1980.
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.
7. Butler JA, Colles CM, Dyson S], et al: Clinical Radiology of the Horse. Oxford,
England, Blackwell Science, 1993.
8. Brown MR Valko K: A technique for intra-articular injection of the equine
tarsometatarsal ioint. Vet Med Small Anim Clin 75265, 1980.
9. Sack WO, Orsiai PG: Distal intertarsal and tarsometatarsal johts in the horse:
Commmication and injection sites. J Am Vet Med Assoc 179:355, 1981.
10. Morgan )P: Techniques of Veterinary Radiography, 5th ed. Ames, Iowa State
University Press, 1993.
11. Han CM, Hurd CD: Practical Diagnostic Imaging for the Veterinary Technician,
2nd ed. St. Louis, Mosby,2000.
12. Stromberg B, Rejno S: Osteochondrosis in the horse. i. A clinical and radiologic
irvestigation of osteochondritic disseens of the knee and hock joint. Acta Radiol
358:139,i 978.
13. Schougaard H, Ronne lF, Phillipson J; A radiographic suwey of tibiotarsal osteo-
chondrosis in a selected population of trotting horses in Denmark and its possible
genetic significance. Equine Vet J 221288,1990.
14. Stephens PR, Richardson DW, Ross MW et al: Osteochondral fragments within
the dorsal pouch or dorsal joint capsule of the proximal intertarsal ioint of the horse.
Vet Surg 18:151,1989.
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-
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

I Normal anatomy shapedsurfacesof the cuboidal bones and by superimpositionof

The equine carpus is composedof sevento nine cuboidal bones
arranged in two rows, the proximal and distal rows, opposed
prorimally by the radius (antebrachiocarpaljoint) and distally by
the three metacarpaibones (carpometacarpaljoint). The middle
carpal joint is between the proximal and distal rows of carpai
bones.
The antebrachiocarpal,middle carpal,and carpometacarpal
joints are synovialjoints. The middle and carpometacarpaljoints
communicate between the third and fourth carpal bones; the ante-
brachiocarpaljoint is separate.r''?
Collectively,there are approxi-
mately 26 side-to-sideand proximal-to-distal bone articulations.
The complexity of the carpus is compounded by the irregularly
thesebones on radiographic projections. This anatomic iomplexity
necessitatesthe use of multiple radiographic views for adequate
examination of the carpal region.
I Radiographic examination
Five standard views are recommended for radiographic evaluation
of the carpus': the dorsopalmar (Dpa), lateromidiil (LM), flexed
lateromedial (FLM), dorsolateral-palmaromedialoblioue (DL-
PaMO ), and dorsomedial-palmarolaieral oblique(DM - pa[O ) views
(Fig. 20-f). The exact positioning used to produce the oblique
views.is described by identifiuing the degree of obliquity from the
dorsal aspectof the carpus.Therefore,the oblique views are more
appropriately termed the dorsal 60-degreelateral-palmaromedial
22A A P P E NDI CU L ASK
R EL E T O N -EOU IN E

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-
lateral oblique (D60'M-PaLO).
In addition to the five standard views, oblique views made
tangential to the dorsal surface of the carpus during flexion are
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
varied to project either the dorsal aspectof the distal radius or the
proximal row or distal row of carpal bones6(Fig. 20-3). In general,
the DPr-DDiO views of the dorsal surface of the carpus are ob-
tained when there is carpal joint effusion and an abnormality to
explain the clinical signs is not apparent or is incompletely evalu-
ated on the five standard proiections.
I Radiographic interpretation
For standardization, it is recommended that carpal radiographs be
olaced on the illuminator in a routine fashion. The soft tissuesand
skeletal margins should be evaluated with a bright or "hot" light
unless computed radiography or xeroradiography is used to in-
creaselatitude and soft-tissue contrast so that subtle chio fractures
or soft-tissue abnormalities are not overlooked.
I Normal anatomic variations
The distal radius forms from trvo centersof ossification-the distal
radial epiphysis and the distal ulnar epiphysis (lateral styloid
process). Fusion of the two epiphysesoccurs as early as 3 months
or as late as 9 months of age, depending on the breed (Fig. 20-4).
A radiolucent line or cyst-like oval radiolucency is occasionally
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.
Closure of the distal radial physis occurs at betrveen 20 and 36
months. A vestigeof the distal ulna is occasionallyseenon the DL-
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 20-3. Dorsoproximadorsodistaltangentialradio-

graphi cproj ecti ons. A , N ormaltrabecul arpatternto the bone
i n the radi aland i ntermedi ate carpalbones i n the oroxi m al
row. B, Normaltrabecularpattern to the bone of the radial
and i ntermedi ate fossaof the thi rd carpalbone i n the di s tal
row . C , S cl erosiof
s the radi alfossa.Thi sscl erosi iss common
i n racehorses and may predi spose to fracturesanddegene ra-
ti ve i oi ntdi sease.

Figure 204. Normaldistalradialand ulnarphyses

of a young foal. The distal ulnar physis /arowsl is
e v i d e n to n t h e d o r s o p a lm a/A/
r a n d d o r so la te r a l- p a l-
m a r o m e d i aol b l i q u e1 8 )vie ws.T h e e p ip h ysissh o u ld
n o t b e c o n f u s e dw i th a la r g efr a ctu r efr a g m e n t.
2 3 O A P P E NDI CU L AR
S KE L ET ON -EOU IN E
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
The first carpal bone is more often present in the distal row
than is the fifth carpal bone (Fig. 20-6). These carpal bones are
usually small and round or oval in shape.A cystJike lucent defect
is sometimes identified in the adjacent aspect of the second carpal
bone and the base of the second metacarpal bone in association
with the first carpal bone, or in the fourth carpal and metacarpal
bones in associationwith the fifth carpal bone. These radiolucent
regions are considered incidental findings and are of no clinical
significance.
The accessorycarpal bone occasionally develops from two cen-
ters of ossification in Thoroughbreds. Incomplete fusion of these
centersis radiographically identified in some weanlings (Fig.20-7).
Identification of this accessorycenter of ossification is an incidental
finding. This physis usuaily fuses at between 5 and 7 months.
II Disorders of the equine
I Garpus
Soft-tissue swelling
Soft-tissue swelling may be intracapsular (within the joint), extra-
capsular (outside the joint), or both (Fig. 20-8).2 8 Each of the
three carpal joints has a distinct joint capsule with specific origins
and attachments,including the previously mentioned communica-
tion betrveen the middle carpal and carpometacarpal joints (Fig.
20-9). The LM and D60'L-PaMO views are best for identifiing
joint distention. Joint distention may represent effusion, slmovial
l di ng.
proliferation, or both, and may result from synovitis, osteoarthritis,
fracture, or septic arthritis. A radiographic diagnosis of synovitis is
unusual but should be considered when no bony abnormalities
4 fe r h n 4 fe n t
Extracapsular swelling on the dorsal aspect of the carpus can
representa hygroma, synovitis of an extensor tendon sheath,bursi-
tis, abscessor cellulitis, sgrovial hernia of the antebrachiocarpalor
middle carpal joint capsule (ganglion), or carpal joint/extensor
tendon sheath fistula (Fig. 20-10). A hygroma is a subcutaneous
sprovial bursa that forms as a result of trauma. The swelling is
tlpically diffuse over the dorsum of the carpus and extends from
the distal radius to the proximal portion oflhe third metacarpus;
the ma-ximum degreeof swelling is not at the level of a joint.' The
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;
then it may be focal or locally extensive.Tiaumatic tendon sheatfr
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
segment of the third metacarpus, and has an indentation at the
level of the proximal row due to compression by the extensor
retinaculum. Synovitis of the extensor carpi radialis tendon sheath
occurs secondary to partial or complete rupture of the extensor
carpi radialis in foals younger than 1 week of age and can be
primary or secondary to flexural deformity.
Swelling on the palmar aspectof the carpus can representcelluli-
tis or carpal canal svndrome.e'r0 The most common cause of
 The E oui neCar ous 231

Figure 20-6. The first (C1)and fifth

(C 5 )c a r p a lb o n e so f te n r e se m b lese sa -
m o i d b o n e s .A , D o r so p a lm aprr o ie ctio n
.lani^r'n^ hnth r^1 rnd l^6 R l l 9n 169
d o r s o m e d i a l - p a l m a r o la otebrliq
a l u eiDM -
P a L O )p r o j e c t i o nC. C 5 o n th e d o r so la t-
e r a l - p am a r o m e d i ao b llq u ep r o je ctio n .
D . A n o ' m a l c y s t l i ke' o ssa ir C2 a n d
M C 2 i n a s s o c i a t r owith
n C1 o n a DM -
P a L Op r o j e c t i o n .
2 32 A P P E NDI C U L AR
S KE L ET ON -EOU IN E
Figure 2O-7. Incomplete fusionof a separate in the
centerof ossification
accessory
carpalboneon a close-up projection.
f exedlateromedial
chronic carpal canal syndrome that can be identified radiographi-
cally is fracture of the accessorycarpal bone, resulting in callus and
fibrosis.t''12Fractureson the palmar aspectof other carpal bones
can result in carpal canal distention and intracapsular swelling
(Fig. 20-11).13Osteochondromaof the distal radius is uncommon
but easily identified as a variably sized, focal, bony protrusion on
the palmarolateralaspectof the radius on the D60'L-PaMO view.tn
Other causes of carpal canal syndrome, including tendinitis and
carpal sheath synovitis, are usually diagnosed by means of ultra-
sonograpny.
Mineralizations within the soft tissue adjacent to the carpus can
represent dystrophic mineralization of any soft-tissue structure
secondaryto trauma or corticosteroidinjection,t5or osteochondro-
matosis within a syrovial structure. The size, shape, location, and
degreeof dystrophic mineralization are variable (Fig. 20-12). Os-
teochondromatosesare identified as focal or multifocal, well-min-
eralizednodules within a slmovial structure (Fig. 20-13).
Figure 20-8. Intracapsular and extracapsular
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)
a l ,m id d le ,a n d ca r p o m etacarpal
/ 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.
Cor n e lV l e t 6 1 : 6 6 6 ,1 9 7 1 .)
Figure20-9. Theoriginsandattachments of thejointcapsuleof thecarpus.
Themiddlecarpal jointcommunicate
andcarpometacarpal between thethird
andfourthcarpal jointcavityremains
bones,butthe antebrachiocarpal sepa-
rate.l(lilustration
fromO'BrienTR,Morgan JB parkRD,et al:Radiography in
equine carpallameness.
CornellVet61:666,1971.)
Although the iocation of soft-tissue swelling or mineralization
of carpal structures can be suggestiveof the cause,ultrasonography
or contrast radiography may be indicated to determine the exact
etiology (Fig. 20-l ). Communicationsbetween fluid-filled struc-
tures and the carpal joint may be confirmed by contrast radiogra-
phy or by ultrasonography with compression. Proliferative synov-
ium may prevent fluid from flowing back into the joint, so the
joint or tendon sheath should be iniected first unless cellulitis is
suspected.
Carpal fractures
Although random traumatic events can result in fracture of any or
multiple carpal bones (Fig. 20-15), most carpal fracturestend to
occur at specific sites and predominantly in racehorses.The occur-
rence of more than one fracture in the equine carpus is not
uncommon; therefore, radiographs should be evaluatedcompletely
and consideration given to obtaining additional views if any lesion
is not adequatelylocalized. Any carpal fracture should be examined
to determine whether it is acute or chronic. The margins of an
acute fracture are sharp and well defined. A chronic fracture frag-
ment has rounded edges.Degenerativejoint diseasemay be pre-
existing and may predisposeto fracture, or it may occur secondary
to chronic fracture. The prognosis and treatment plan for carpal
fracture usually require the DPr-DDiO projections. The size and
thickness of the fragment, degree of comminution, presence of
additional fractures or fissure lines, degree of subchondral bone
sclerosis, degree of displacement, and degree of reduction with
flexion affect the prognosis and surgical plan. Postsurgical radio-
graphic examinations are useful for assessingthe degree of bony
union, the stability of the surgical implants, and the alignment of
the fracture fragment(s). Remember that radiography has limita-
tions and does not enable evaluation of articular cartilage, synovial
membrane,and intra-articular liqaments.l5
Ghip fractures
Carpal fractures are usually classified as chip or slab (including
soft t;ssue swe ling. intracap- sagittal), and simple or complex. Chip fractures are the most
j oi nts
common type of carpal fracture; these are seenas small periarticu-
.
Iar bony fragments. Chip fractures of the antebrachiocarpal joint
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.

Figure 2O-11. Soft tissue swelling on

th e p a l m a ra s p e c to f th e ca r p u s.A sm a ll,
s m o o t hc h i pf r a c t u r ein th e p a lm a ra sp e ct
of the carpuson lateromedial(A) and dor-
solateral-palmaromedial obiique(B)projec-
ti o n s i n a h o r s e w i t h m ild o ste o a r th r itis.
The originof the fractureis not apparent.
2 3 , 4 A P P E NDI C U L ASK
R EL E T O N -EOU IN E

Figure 2O-12. Dystrophicsoft tissue

mineralizationof the carpus.Focallyex-
a dj ac entto the
tensi ve mi neral i zati on
middle carpal joint on lateromedial(A)
and dorsol ateral pal maromedi oblal i que
/BJ projectionsin a horse with a firm.
dorsalswelling.Ultrasonography or con-
trast radiographycan be usedto confirm
the locationof soft tissuemineralization.

Figure 20-13. Synovialosteochondromatosis distributedalongthe planeof a tendon sheathon the close-up

of the carpus.A, Multiple,small mineralizations
of the mineralizednoduleson the flexed lateromedialprojectionconfirmstheir location.
lateromedialprojection.B. Redistribution
 The EquineCarpus 235

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

l o n e( Cu ) .Mul ti pl efracturel i nesw i th margi nal

Figu r e 2 0 - 1 5 . C o m p le xfr a ctu r eo f th e u ln a rca r p a b commi nuti on
i n the C u on dorsol ateral pal m arol ateral
obl i que
/A/ and dorsopalmar/8/ views.

and Quarter horses. Chip fractures at the level of the antebrachio-
carpal joint are rare in Standardbreds.Most radial chip fractures
originate from the dorsolateral aspect of the distal radius, lateral
to the ridge iocated lateral to the midline (Fig. 20-16). Therefore,
these chips are best identified on the DM-PaLO and LM views.
Chip fractures from the dorsomedial aspectofthe distal radius are
lesscommon. Chip fractures of the proximal aspectof the interme-
diate carpal bone are also common (Fig.20-17). These chip frac-
tures may be very small and are best identified on the FLM view,
as are those originating from the proximal aspect of the radial
carpal bone (Fig. 20-18). Complete evaluation of fractures oc-
curring at the level of the antebrachiocarpal joint requires the

Figure 2O-16. Chronicchip fractureof the antebrachiocarpal joint. A rounded,minimallydis-

pl acedchi pfractureori gi nati ng
from the dorsol ateral
aspectof the di stalradi uson th e dors omedi al
pal maromedioblal i queproi ecti on.
 The E oui neCar pus 237

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

F i g u r e 2 O - 1 8 ' A n o n d isp la ceddo r so p r o xim ainl te r m e d iate

carpalbone chi p fracturemay be di ffi cul tto i dentfy.A , Therei s a peri arti cul ar
i rregul ari ty
on the
lateromedialprojection(arrow).B, The fracture is identified (arrow)originatingfrom the dorsoproximaaspect of the intermediatecarpalbone on the flexed
l a t e r o m e d i aolr o i e ctio n .
23A A P P E NDI CU L ASK
R EL E T O N -EOU IN E
acquisition of DPr-DDiO projections of the distal radius and proxi-
mar row.
Chio fractures at the level of the middle carpal ioint are common
in Thoroughbreds and Quarter horses and' aie uncommon in
Standardbreds,although most chip fractures in Standardbredsoc-
cur at this joint.l7-ie Chip fractures of the dorsodistal aspect of the
radial carpal bone (Fig. 20-19) and the proximal aspect of the
third carpal bone are common in Thoroughbreds, Standardbreds,
and Quarter horses (Fig. 20-20). These chip fractures are best seen
on the DL-PaMO and FLM views. Chip fractures originating from
the distal aspect of the intermediate carpal bone occur less com-
monly. Chip fractures from the dorsodistolateral corner of the
radial carpal bone occasionallyoccur and are best identified on the
DM-PaLO view. Complete evaluation of fractures occurring at the
level of the middle carpal joint requires the use of DPr-DDiO
projections of the proximal and distal rows. The DPr-DDiO projec-
tion of the distal row is essentialto the diagnosis of third carpal
bone sclerosisand of nondisplaced slab and sagittal fract:ures.a'2o 22
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
the collateral ligaments, and radiographs obtained while stress is
applied to enhancevisualization of the laxity of the affected aspect
of the carpus are useful in identifring instability.'z3Ultrasonography
can be used to identifr the extent of ligamentous damage.
Slab fractures
Slab fractures extend from one subchondral surfaceto another and
involve two joint spaces.Most slab fractures originate in the dorsal
plane from the third carpal bone (Fig. 20-21).t?''u26Third' carpal
bone slab fractures are usually identified on the DL-PaMO and
DPr-DDiO views. Very large slab fractures and those of the lateral
corner may be seen on the DM-PaLO and DPI-DDiO views. Slab
fractures only identified on the DPr-DDiO view are usually incom-
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
plete. Small chip or wedge fractures frequently occur at the proxi-
mal margins of complete third carpal slab fractures (see Fig. 20-
21). These chip fractures are seen on the FLM and DPr-DDiO
views. Slab fractures of the fourth; radial and intermediate carpal
bones are uncommon, and slab fractures of the ulnar and second
carpal bones ate lare.l3'22'2''28
Sagittal fractures are considered a form of slab fracture; they
occur primarily in the third carpal bone.20,2e Most occur on the
medial aspect and are minimaliy displaced. These fractures are
usually identified only on the DPi-Onb view. Sagittal fractures in
the radial or intermediate carpal bones are rare (Fig. 20-22).
Accessory carpal bone fractures
Most fractures of the accessorvcaroal bone occur in the dorsal
plane and are nonarticular. These fiactures are identified on the
LM or FLM view Accessory carpal bone fractures can occur in
racehorsesor event horses following a fall. Comminuted accessory
carpal bone fractures occasionallyoccur.
orthoPedic
I 3r:::'""*-ental
Osteochondrosis
Radiolucent cyst-like lesions in the carpal region are common,
and most nonarticular and small articular lesions are considered
developmental and incidental findings.'o These incidental cyst-like
lesions are most common in the ulnar carpal bone (seeFig. 20-58)
but also occur in the radial, accessory,second, and fourth carpal
bones. Subchondral cyst-like lesions in the medial aspect of the
distal radius have been associatedwith lameness (Fig. 20-23).31
Tiauma, rather than a developmental anomaly, may be responsible
for some cyst-like lesions. Very large or multiple ryst-like lesions
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 20-2O. Nondisplacedchip fracture of the third

carpalbone.The fracturecannotbe i denttfi ed on the fl exed
iateromedialprojection1A./,but ls seen on the dorsolateral-
pal maromedi a obl i que(D L-P aMO) proj ecti onat rhe mi dde
carpaljoint \8, arrows).The fractureapoearsincomDleteon
tl -e D L-P aMOp oecri or. C . fre oorsoproxi rral -dorso di s rar
obl i que(D P r-D D i O)
prol ecti ondepi ctsa compl etefractu re.
The D L-P aMOand D P r-D D i O vi ew s rogetheri denti fythi s as
a chip fracturein contrastwith a slab fracture,which would
extendto the carpometacarpal j oi ntand i nvol veboth i oi nts.
2 4 O A P P E NDI CU L ASRKE L ET ON -EOU IN E

Figure 20-21- Thirdcarpalslabfracture.A smallchip adja-

cent to the proximal margin of the third carpal bone on
the flexed lateromedial/Al view results in articularsurface
incongruity.Slab fracture of the third carpal bone on the
dorsolateral-palmaromedial oblique /B/ view On the dorso-
proximal-dorsodistal oblique /C/, the slab and chip fractures
are both vi si bl e.

Fi gure 2O-22- S agi ttalfractureof the i ntermedi atec arpal

bone. Fracturel i ne i n the sagi ttalpl ane on the do rs oprox i mal -
dorsodistalobliqueview. Sagittalfractureof the third carpalbone
i s more common.

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
may result in lameness and degenerativejoint disease or carpal
fracture (Fig.20-2a). Bone scintigraphymay be useful for evaluat-
ing the activity and clinical significance of unusual carpal cyst-
like lesions.
Physitis
The term physitk is used to describe developmental changesat the
level of the physeal growth plate; this is aiso known as physeal
dysplasia (formerly epiphysitis). Physitis of the distal radius is
common in yearlings and immature horsesthat have been prepared
for competition. The distal radial physis is asymmetrically widened
and irregular (Fig.20-25A).In more severeinvolvement,metaphy-
seal sclerosis, metaphyseal and epiphyseal flaring (buttress), and
cortical thickening are radiographically apparent (Fig. 20-258).
The disease may resolve prior to or during distal radial physis
closure at between 20 and 24 months of age.
Incomplete ossification or hypoplasia
of the carpal bones
Each carpal bone normally develops from a single separatecenter
of ossification.In the normal foal at birth, the cuboidal bones of
the carpus are completely ossified and the corners are nearly angu-
lar. Incomplete ossification or hypoplasia of the cuboidal bones is
usually identified in premature or twin foals, including miniature
foals (Fig. 20-26).32These immature carpal bones appear small and
rounded with wide joint spaces.33'3aWith weight bearing,the carpal
bones can become misshapen,particularly the smailer bones on
the medial or lateral aspect of the joint, which may result in an
angular limb deformity. The third, fourth, and ulnar carpal bones
are the last to ossif' during gestation. When hypoplastic, these
carpal bones are the most susceptibleto injury, resulting in a high
incidence of valgus deformity. Sclerosis,deformity, and compres-
sion (crush or collapse)fracture of the cuboidalbones (Frg. 20-27)
with subsequentdevelopment of osteoarthritis may occur without
proper treatment. This change most frequently involves the third
carpal bone and is similar to collapse of the third tarsal bone;
The EouineCarous 241
Thi s l esi oni s usual y cl i ni cal lsi
y gni fi cant.
however, other carpal bones may be affected. Radiographs of the
carpus and tarsus are recommended in all premature, dysmature,
and twin foals to enable identification of hypoplastic bones so that
proper treatment can be initiated to prevent osteoarthritis.
Angular limb deformities
Development of angular limb deformity is multifactorial; it may
,t..6 Congenital factors that
be either congenital or acquired.32,
contribute to angular deformity include abnormal in utero posi-
tioning, in utero chemical insult, hormonal or nutritional imbal-
ance, and immaturity of musculoskeletal structures, resulting in
joint laxity or incomplete ossificationof cuboidal bones.Develop-
mental factors that contribute to the pathogenesisof angular defor-
mity in foals include nutritional imbalance or excess,poor confor-
mation, excessivegrowth, excessiveexerciseor overloading of the
limb, and trauma to the distal radial physis, radial epiphysis,
or cuboidal bones. Severalmusculoskeletalabnormalities,such as
immaturity of ligaments, dysplasia of the growth plate, dysplasia
of the distal radial epiphysis,incompleteossificationor hypoplasia
of the carpal bones, diaphyseal deformity (which is rare), acute
physeal trauma, physeal sepsis,and preferential limb use, contrib-
ute to angular limb deformity; most of these can be identified
radiographically.
In cases of severe angular deformity or deformity with acute
onset of lamenessor swelling, multiple radiographic projections
are recommended.In other cases,a DPa radiographic projection
obtained using a 7 x 1,7-inchcassetteand centeredon the carpus
with an optional lateromedialprojection is adequate(Fig. 20-23).
The degree of angular deformity is measured from lines drawn to
bisect the radius and third metacarpal bone. Geometric analysisof
the deformity is obtained by drawing lines through the distal radial
physis and antebrachiocarpal,middle carpal, and carpometacarpal
joints. The exact structures contributing to the deformity are accu-
rately assessedin this way.37Normally, the lines drawn through the
long axis of the distal radius and metacarpusare confluent, and
lines drawn through the distal radial physisand antebrachiocarpal,
242 A P P E NDI CU L ASRKE L ET ON -EOU IN E
Figure20-24. l\,4ultiplecystlike in the secondcarpalbone.Close-up
lesions
obliqueview depictsmultiplecystsin the second
dorsomedialpalmarolateral
carpalbone(C2)in a horsewithlameness remod-
Signlflcant
andosteoarthritis.
elingof C2wasdemonstrated by bonescintigraphy.
middle carpal, and carpometacaryaljoints are parallel to each other
and perpendicular to the lines bisecting the long bones. Deviation
of metacarpus and foot to the lateral aspect of the limb is called
carpal valgus and results in knock-kneed conformation. Medial
deviation is called carpal ttarusand results in bow-leggedconforma-
tion.
Joint instability may be related to flaccid or damaged periarticu-
lar structures, such as collateral ligaments. foint instability from
damaged or lax ligaments usually placesthe pivot point of the long
axis lines at the level of the distal articular cartilage of the radius,
and the cuboidal bones are usually not radiographicaliy abnormal.
Imbalanced growth of the distal radial metaphysishas a pivot point
approximately at the level of the physeal growth plate, the physis
is widened on the side of the limb opposite the deviation, and
lines through the long axis of the radius and distal radial physis
Figure20-26, Incomplete of the carpalbones.Notethe subtle
ossification
mineralization
withinthe radialand intermediatecarpalboneson the dorso-
palmar
viewof a premature foal.
are not perpendicular. Epiphyseal growth imbalance places the
pivot point between the joint spaceand the physis, the distal radial
epiphysisis wedge-shaped,and lines through the distal radial physis
and antebrachiocarpaljoint are not parallel. Ossification defects of
the cartilaginous precursors of the cuboidal (carpal) bones have a
pivot point corresponding to the area involved, and lines through
the joint spacesare not parallel. Location of the pivot point is not
always reliable as abnormalities may occur in combination; there-
fore, all bony and soft-tissue structures should be evaluated.
I Septic arthritis
Acute septic arthritis produces intracapsular distention and severe
lameness. Septic arthritis is most common in foals and occurs
secondary to extension from osteomyelitis (septic physitis) (Fig.
Figure 2O-25. Physitisof the distalradius.A,
Wi deni ngandi rregul ari ty
of the m edi alas pec tof
the di stal radi alphysi s,w hi ch i s i ndi c ati v eof
mild physitis.B, Wideningand sclerosis/stngle
pointed arrows)of the dlstal radialphysis /dou-
ble arrow)wilh prominentflaringof the adjacent
metaphyseal and epi physeal bone (w hi te
affowsl consistentwith severephvsitis.
 The EouineCarous 243

Figure 2O-27. Carpalcrushor collapse

as a result of incompleteossification.A
nondisplaced f r a g m e n t { p a th o lo g icfr a c-
ture) originatesfrom the dorsalmarginof
t h e t h i r d c a r p a lb o n e o n th e la te r o m e d ia l
(A) view. The third carpalbone is abnor-
m a l l ys h a p e da n d c o mp r e sse d in th e p r o x-
im a l - d i s t adli r e c t i o n{ cr u sh e d
o r co lla p se d ) ,
p a r t i c u l a r lm
y e d i a l l y,o n th e d o r so p a lm a r
(B)view.

Figure 20-28. Angular limb defor-

mity. A, Medial deviationof the distal
limb in the right carpusis calledcarpal
varus. C2 is abnormallyshaped and
ossified.B, Deviationof disrallimb to
the lateral aspect, carpal valgus.C4 is
wedge-shaped. A foal with both carpal
varus and carpalvalgusdeformitiesis
cal l ed"w i ndsw ept. "
244 A P P E NDI C U L ASRKE L ET ON -EOU IN E

Figure 2O-29. Septic arthritis sec-

ondaryto septicphysitisin a foal.A, The
medialaspect of the distal radialphysis
is widened with focal lysis of the dor-
somedialaspect of the metaphysisand
epiphysis.Sclerosissurroundsthe lytic
bone and extendslaterally.

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

Figure 20-31, Osteoarthritiswith exostosis. Large exostosis on the dorsal

aspect of the radialcarpal bone with periarticularosteophytesat the antebra-
c h i o c a r o aaln d m i d d l eca r o a io
l in ts.

DDiO projection of the distal row.'zIA significant amount of pro-
ductive or l1tic change must occur before radiographic signs are
visible. Therefore, subtle radiographic abnormalities should be con-
sidered significant in any horse with lamenessthat is localized to
the carpus. Exercise-relatedsclerosisofthe third carpal bone occurs
in horsesduring training and racing.n0 In racehorses, enthesophltes
of considerablesize (exostosis)sometimes form on the dorsal
aspect of the radial or intermediate carpal bones (Fig. 20-31).
Osteoarthritis of the carpometacarpaljoint has been reported in
performance horses.arNarrowed joint space, sclerosis,small cyst-
like lucencies,and periarticular osteophltes and enthesophltes have
been identified (Frg. 20-32).

Figure 2O-32- Osteoarthitis of the

carpometacarpal joint. Narrowedjoint
s p a c e ,s c l e r o s i ss, m a ll cystlikelu ce n -
c ie s ,a n d p e r i a r t i c u l ar
oste o p h yleas n d
en r h e s o p h y t e sa r e i d e n tifie da t r h e
carpometacarpal joint.
246 SK EL E T O N -EOU IN E
A P P E NDIC U L AR

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
Third metacarpus and third metatarsus-the
cannon bone
Radiographically, the third metacarpus and metatarsus (MC nI
and MT III) are basicallythe same (Fig. 21-1). The midportion of
the dorsal cortex is thicker than the remaining cortex, and it
thins gradually toward the ends of the bone. This variable cortical
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
foramen. Unlike the nutrient foramina of smaller bones, those in
MC III and MT III are like channels, which may be mistaken for
a fracture on lateral and oblique views, especiallyin the rear limb
(FiS.21-2).
The palmaroplantar cortex is flattened proximally, often resulting
in visualization of both medial and lateral aspectson a lateral view.
There is no visible proximal physis at birth. The distal epiphysis is
within the metacarpophalangeal(metatarsophalangeal)joint and is
one of the first sites to become abnormal in metabolic bone
disease,although its appearancevaries in the normal animal at
different ages.
On the lateral view, the metacarpus and metatarsus differ at the
distal end (see Fig. 2l-1). The metacarpusis relatively straight,
whereas the distal end of the metatarsus usually curves slightly,
giving the dorsal border a slightly convex appearance.
Second and fourth metacarpi and
metatarsi-the splint bones
These small bones articulate with the carpus or tarsus and taper
distally. The size and shape are variable between animals and
between limbs.] There is a variable degree of natural outward
curvature. The distal end is usually in the form of a slight bulbous

*
I
I

Figure 21-1, Normal lateral radiographsof the metacarpus/AJ and the

metatarsus(B/. Note that the metacarpusis straight,whereasthe metatarsus
c u r v e ss l i g h t l ya t t h e d ista le n d . T h e d o r sa lco r te xin b o th bones s thl cker,
e s p e c i a l l ya t t h e mid p o r tio nT. h e la r g e n u tr ie n tfo r a m e n is evl denti n the
metatarsus/arroW.
Figure 21-2. Lateral1// and dorsomedial-plantarolateral iBl views of the left
metatarsus of a 1-year-o
d Thoroughbredcol t.The nutri entfo ramenappearsas
a channelthroughthe plantarcortexof metatarsalIMT) lll (arrows).

247
24A S KE L ET ON -EOU IN E
A P P E NDI CU L AR

enlargementof variablesizeand shape,but the margins are smooth

and distinct.
In the forelimb, the medial splint bone (MC II) is usuallylonger
than the lateral (MC IV), although MC IV may be the same length
or longer than MC IL In the rear limb, when comparedwith MT
II, MT IV is relatively massiveand irregular at the proximal aspect,
often extending proximal to MT III.
The proximal epiphysis of the splint bones, apparently present
in the fetus, is fused at birth. The distal epiphysis is cartilaginous
and, therefore, is not visible radiographically at birth. As it ossifies,
the distal epiphysis is separated from the body of the bone by
cartilage until fusion occurs. Care should be taken to avoid mistak-
ing the normal epiphysisfor a fracture (Fig. 21-3).

Mach bands-false fracture lines

A visual phenomenon in radiography that causessome confusion is
edgeenhancement,or mach bands.tThis phenomenonis especially
evident in radiographs of equine metacarpi and metatarsi' Simply
stated,as one bone edgecrossesanotheron a radiograph,a radiolu-
cent line may appear. This line may often be seen on the pal-
mar or plantar aspect of the equine metacarpus and metatarsus,
resulting in erroneousdiagnosesof cortical fracture of MC III or ;u
MT III, as well as fractures of the smaller metacarpal and metatarsal 'd q
bones (Fig. 2l-4). To guard againsterroneousdiagnoses,the ana- iilltrr',irlgrrr.,r

tomic contour of each bone must be followed carefully, with addi-

tional radiographsobtained for clarification as needed.

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

Figure 21-6. Lateralview of the eft metacarpus of a 2-year-old

racing
Ouarter
horse.Thereis a layerof periosteal
newboneonthedorsal aspectof
themidporlonof MC lli.TherightMC lll hadsimilar
changes.

ligament. Splint diseaseis discussedmore thoroughly in the follow-

ing section.

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

Figure 2I-7. Dorsomedial-palmarolateral radiographs of the metacarpalregionof severalhorseswith differentappearances of damagedinterosseousligaments

(" s pli n tl e s i o n s " )A ldh o r o u g h b r egde ld in g( h u n te r-j umper)
. . A 1 3- ye a r - o T w l th a recenti nterosseous i nj ury.A sl i ghtperi ostealresponseand a smal lamountof
corticalbone lysisare evident.This is the typicalappearanceoI a 2- to 3-week-oldlesion.8, A 3-year-oldStandardbred gelding.The periostealresponseis more
organizedbut still active.lt involvesmost of the attachmentareaof the interosseousligamentwith a separatesite of reactionproximally(arrow).C, A 2-year-old
Standardbred gelding.As in B, this lesionis chronic,but appearsactive,and most likelyis at least6-weeks-old.The periostealreactionis largeand opaqueover a
loc ali z e a d r e a ,b u t i t h a s no t b e co m esm o o th .T h e la r g em a ss m a y produceabnormalpressureon surroundi ng soft ti ssues.The nutri entforamen/arrod s houl d
not be c o n f u s e d w i t h a l e sio n .D,A2 - ye a r - o ld T h o r o u g h b r e d fill y.Thel esi ononthemi dporti onof MC l l i si nacti ve.Thi si stypi cal
of a3-to6-w eek-ol dl es i onthat
has been protectedwith rest. Sucha lesionwould be expectedto becomesolidwith no enlargement.E, A S-year-old Standardbred gelding.The lesionis nearthe
distalend of metacarpalIMC\ ll (arrow).lt is opaqueand smooth, blendingtogetherwith the cortex of MC ll and MC lll as a chronicinactivelesion.Lameness
may r e s u l tf r o m c o n c u s sio n o f M C ll a n d th e in te r o sse o uIig s a m ent,exaggerated by the di stalfusi onof MC l l to MC l l l . The appearance of the pr ox i malend i s
c aus e db v o v e r l a oo f M C l l, IVC lll, a n d M C lV
 The Metacarpusand Metatarsus 2|51
--€

,-#
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:::;

Figure 21-8. Dorsomedial-plantarolateral view of metatarsal(MT) ll /A/ and

dorsolateral-pantaromedial view of MT lY (B) in an 8-year-oldStandardbred
ge l d i n g .S o f t - t i s s u ee n la r g e m e nis
t p r e se n t o n th e p la n ta rsurfaceof the
m e t a t a r s aal r e a . M T l l is d e via te dsh a r p lya t th e d ista le n d , and MT l V i s
separated f r o m M T l l l. Bo th M T ll a n d M T lV h a ve in d istr n cmarqi t nson the
dis t a le n d s ,w h c h i s c o n siste nwith t 0 e r io ste airl r ita tio n .

Cortical bone abnormalities

Cortical lysis in the metacarpal and metatarsal bones is usually
associatedwith localizedtrauma. Injury to the periosteum of MC
III or MT III may causedeath of the outer one third of the bone,
with a resultingsequestrum(Fig. 21-9). This is relatedto the thick
cortex of these bones, and the inability of the endostealblood
supply to maintain viability of the dorsal cortex following periosteal
disruption.
Following damage to the interosseousligament, multiple small
lytic lesions may be seen along the opposing surfacesof the meta-
carpal and, less often, metatarsalbones, presumably becauseof
disruption of fibrous attachments and resultant inflammation.
Metacarpal and metatarsal fractures are common, especially in
racing horses.The most common fracture site in these regions is ;-.-",
the distal one half of MC II and IV and MT II and IV. As has
been mentioned previously, care must be taken to avoid mistaking -'
cartilaginous plates and mach bands for fractures. Fractures may
also occur in the proximal one half of MC II and IV and MT II I

and IV and these fractures may be mistaken for typical "splints."

Aside from complete fractures of MC III and MT III, which are
obvious, incomplete fractures may be difficult to diagnose. They
do, however, occur in specific locations. These incomplete stress
fractures are usualiy seen in racing horses. The lesion most readily
diagnosedis the sagittaldistal condylar fracrure (Fig. 21-10). This
fracture frequently affects MC III, extending proximally from the
metacarpophalangeaijoint; it may or may not be significantly
displaced.Often this fracture may be seenonly on the dorsopalmar
Figure 21-9. ,4, Lateralview of the right metatarsalregionof a 3_year_old
Ouarterhorsemare 10 days after the l i mb w as severel yi nlured,ex pos i nga
large portionof metatarsal(MT) lll. The large radioluceniareasoveriyingihe
MT l l l are due to mssi ng porti onsof soft ti ssue. A fai nt, dark/rnei s prJ s ent
within the dorsajcortex of MT lll (arrow),indicativeof fractureor tmpenornq
sequestrati on. 8, A l ateralvi ew ,3 w eeks l ater.The sequestered bonec an now
be seento extendproxi mal l y. P eri osteal
responsei s presenta roundthe l es i on.
252 A P P E NDI C U L ASRKE L ET ON -EOU IN E

Figure 21-1O. Dorsopalmarradiographof the left front limb of a 4-year-oldThoroughbredstallion.A

sagittalfractureis presentin the lateraldistal condyleof MC lll (arrows).This lesionwas not visibleon
lateralor obliqueviews.

Abnormal shape of MC and MT III results from growth distur-
bance, and is most often seen at the distal end of the bone. This
shape change may be seen as a single, localized problem, or it may
be seen in conjunction with more proximal limb abnormalities.
Although there is considerable variety in the size and shape of
the small metacarpal and metatarsalbones, abaxial deviation of the
distal ends is often associatedwith suspensorydesmitis, presumably
from outward pressure exerted by the enlarged ligaments (see Fig.
21-8). If this outward curving is noted, the suspensoryligaments
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

Figure 21-12. Dorsopalmar(A), laleral (B), and dor-

somedial-palmarolateral (C) radiographsof the nght proxi-
mal metacarpusof a 2-year-oldStandardbredcolt with
acutel amenessi n the ri ghtforel i mb.A fracturei s evi den t
on all three views (arrows)in the medial aspect of the
pal marcortex.On the dorsopal mar vi eW the fracturei s
i denti fi edas radi ol ucent
l i nesthat do not conformto the
normaltrabecul arpattern.A l thoughthe fracturei n thi s
horsei s best seenon the l ateralanddorsomedi al -pal maro-
lateralviews, such fracturesare often only seen on the
dorsopalmarview.
254 A P P E NDI C U L ASRKE L ET ON -EOU IN E
llr.,lllllY
lll)ti :
lrrr'i1illl't'"
Figure 21-13. Lateralradiographof the proximalleft metacarpusof a 3-
year-oldStandardbred with lamenessin the left forelimb.The proximalportion
of t h e m e d u l l a r cy a v i t yco n ta in sa n ir r e g u larre g io no f in cr e a seodpaci tyori gi nat-
ing f r o m t h e p a l m a rc or te x { co m p a r ewith F ig .2 1 - 1 A) .T h is opaci tyresul ts
from endostealbone responsethat is due to injury of the palmar cortex.A
verticalfracturelinewas seen on the dorsopalmarview.
ent deviation should not be considered diagnostic for suspensory
desmitis.
I Ultrasound: Metacarpall
I metatarsal region
Radiographic evaluation of the soft tissues on the palmar/plantar
aspect of the equine limb is severelyiimited becauseof the lack of
opacity interfaces. But, because of differences in tissue character,
diagnostic ultrasound has been found usefui to assessanatomic
structure and diseaseconditions in this area,which contains critical
supporting structures.e''0The superficialdigital flexor tendon
(SDF) and the deep digital flexor tendon (DDF), as well as the
suspensory-interosseousand the "checK' (accessory)ligament' are
made up of dense linear fibers that are more echogenic than
surrounding loose tissue(Fig. 21-15). Becausethesestructuresare
considered rather uniform in echotexture, defects such as hemor-
rhage, fiber disruption, and inflammatory lesions appear as hlpo-
echoic areaswithin the structure. Also, fluid within tendon sheaths
is visible adiacent to structures and tendon sheaths (see Chapter
2). In addition, the cross-sectionalsizeof thesestructuresis rather
uniform. Calipers found on most ultrasound machines allow rela-
tively precise measurement of structures.
Sonographic anatomy of the metacarpal/metatarsal region has
been described.rt-lsThere is, however, reported variation regarding
the normal size and appearance of these structures relative to
21
the type and degree of activity and the age of the patient.l6
Understandine variations between front limbs and hindlimbs, as
well as the effect of the use of the patient, is necessaryto avoid
erroneousdiagnosesand assessments.
Along with variations within patients, technical factors and er-
rors in performance of the examination can severely affect the
appearanceof the image.'z24The quality of ultrasound machines
is extremely variable. Equipment that is satisfactory for one pur-
pose is not necessarilysatisfactory for another. Image clarity and
definition are important when attempts are made to examine
structures that are typically 1 cm or less in thickness. Most probes
scanning at less than 7 MHz are not satisfactory for accurate
evaluation of equine tendons. The ultrasound beam must also be
powerful enough to penetrate to the palmar aspect of the bone.
For full evaluation, it is helpful to be able to change the depth of
interest to allow adequate assessmentof the suspensory ligament
as well as the very-near SDF. Probe design is important to allow
an adequate area of contact between the probe surface and the
limb. The smaller the radius of the probe surface arc, the more
difficult it is to use. Even with excellent equipment, the examina-
tion technique must be exacting. Incorrect alignment of the probe
with the limb may lead to incorrect interpretation. Proximal-distal
malalignment can causeechogenicity of structures to appear differ-
ent. Compare the appearanceof tendons in Figure 21-16 with the
appearance in Figure 21-17. The only difference between these
images is a slight difference in the proximal-distal angle of the
probe with the limb.
Many methods are used to prepare the surface of the skin to
create optimum interface with the probe surface. Some clients are
adverse to clipping the hair. Previous treatment regimens may
produce scabs and blisters on the surface, preventing preparation
of a smooth skin surface,which leads to poor contact between the
transducer and the patient. Proceduressuch as covering the surface
with mineral oil or other concoctions are sometimes used in lieu
of clipping the hair. If allowable, actual shaving of a thin strip
along the tendon surface createsan excellent interface when wiped
with alcohol before use of ultrasound coupling gel. Nearly all
ultrasound examinations of this region are performed with the
transducer perpendicular to the structures (in cross section) from
the palmar-plantar aspect of the limb. Depending on the probe
design,the anatomy of the tendons and ligamentsmay be demon-
strated nicely in longitudinal section; however, becausethe image
is produced from a very thin "siice" of tissue, examination of
these structures in this fashion alone can result in considerable
misinformation. Probe design is also a factor in the production of
imagesin cross section. Unless the tendons are rather large or there
is considerable soft-tissue enlargement due to fluid accumulation,
the surface at the point of probe contact may be small becauseof
the contour of the tendons. This may produce a very narrow
"window" through which clear images may be "seen." With the
curved design of many probes, the echoesare concentrated in the
near field, making superficial structures such as the superficial
digital flexor tendon difficult to demonstrate. To counter this prob-
lem, materials of uniform echogenicity may be used between the
probe and the limb as a "stand-off" device"''u (see Fig. 2l-17).
To aid in communication and for follow-up comparison, the
regions of the limb are divided and identified. Most sonographers
use the zone approach in which the region is divided into six
zones, tlpically labeled 1A', 18, 24, and so forth (Fig. 21-18).
Other methods have been proposed such as using measurements
from palpable structures.2T
Sonographicexaminationof the metacarpal-metatarsal region is
used to add information to the examination procedure. This proce-
dure can be quite helpful for evaluating the extent of lesions and
monitoring healing processes.It should not replace a thorough
lamenessexamination. Sonography is used to identift hypoechoic
lesions in the tendons and ligaments causedby hemorrhage, edema,
and fiber disruption. These lesions may be large central pockets
(core lesions), or they may appear as diffuse disruption (Figs.
21-L9 and, 2l-20). Healed lesions tend to appear isoechoic or
 The Metacarousand Metatarsus 25,5

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:

Figure 21-14. Lareral(A) and plantar1Blscintigraphicimages of

the righttarsa-metatarsalregionof a l O-year-old Thoroughbred mare. rrl!ll:,,.,,rti,:,
rrl!,11r'rrlll::,1.lr1,i,1
A f o c a la r e ao f i n c r e a se din te n sity( u p ta keis ) p r e se n ta t th e pl antar
.:
a t e r aal s p e c to f t h e pr o xim am l e ta ta r su s.
T h isle sio nm u st b e consrd-
e r e d " f r a c t u r eh o t . " Alth o u g hsu ch fin d in g sa r e n o t d ia g nosti cof tltrt iii,l
f r a c t u r et,h e y d o i n d ica tein te n sefo ca lu p ta keo f r a d io p h a r maceuti cal ililrllliiiirlll,,.illl'lll,
i!rll,.,lii:llll :iil,rlll,:iii
'e p ' e s e n r i r g" s e v e re "' o ca l b o n e a ctvty. F r a ctu r e sin tn s regi or' .
m a y b e d i f f l c u l tt o de te ct r a d io g r a p h ica d u e to th e n u mber of
lly
overlappingbone margins (see Figure 214). fhe presenceof the
1,.
ii9ll,,
iiililllll'"::iiall,,illl!lll'..,lli!llll,,l.,,.::l!lll
c sio nm a y stim u la teclo sescr u tin yo f th e areaon
f o c a ls c i n t i g r a p h li e
r a d i o g r a p hos r m o r e r a d io g r a p has t slig h tlyd iffe r e n ta n g lesi n an
attemot to identifvfractures.

Figure 21-15. Crosssectionanatomy.a, Superficialdigitalflexortendon (SDF);

b, deepdi gi tafl exortendoni D D F);c, accessory
(check);d, suspens ory
l i gament.
2 56 A P P E NDI C U L AR
SK EL E T O N -EOU IN E

Figure 21-16, Sonogramof equine tendons. A "stand-off" device

was used; however,the probe anglewas not correct.Noticethe differ-
ence i n appearance
of tendonscomparedw i th Fi gure21 -17.

Figure 21-17. Sonogramof equine tendons.A "stand-off"device

was interposedbetweenthe probeand the skin to allow better visual-
izationof near-fieldstructures.The probe angle is correct.Notice the
clarity of the superficialdigital flexor tendon comparedwith Figure
I t- to.
 The Metacarpusand Metatarsus 257

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

Fi gure 21-19. l l l ustratronof an equi netendonu l tras ound i mage.

A large hypoechoiclesionas depictedin the SDF s often referred
to as a "core" l esi on.The speckl ed"chocol ate
ch i pc ook i e"appear-
ance of the suspensoryl i gamenti s i ndi cati onof a more di ffus e,
l essseverel esi on.
25A A P P E NDI CU L ASK
R EL E T O N -EOU IN E
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
. , 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
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
hyperechoic to the surrounding structure. Depending on the time
ofsonography relative to an injury, a lesion will vary in appearance
relative to the stage and degree of healing. As with any modality,
improper use may lead to erroneous diagnosesand conclusions. In
addition to general consideration of the major tendons and liga-
ments, specific diagnoseshave also been published by authors with
extensive experience with the modality.'z830A word of caution is
necessaryat this point. A number of parameters that may lead to
misinterpretation have been mentioned earlier, including suitability
of equipment, understanding of imaging physics,and patient varia-
tion. In addition to the patient variation referenced previously,
vascular structures and previous injuries may cause confusion.
Thorough knowledge of the local anatomy is imperative. It is
important that the clinician fully understand the modality and its
use through training and experiencebefore depending on it with
client-owned animals. Excellent textbooks are available that deal
specificallywith sonography.3l'3'
References
1. Getty R: Sisson and Grossman's The Anatomy of the Domestic Animals, 5th ed.
Philadelphia, WB Saunders, 1975.
2. Lane EJ, Proto AV, Phillips TW: Mach bands and density perception. Radiology
I2l:9, 1976.
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.
4. Lloyd KCK, Koblik P, Reagle C, et al: Incomplete palmar fracture of the proximal
extremity of the third metacarpal bone in horses; Ten cases(1981-1986). J Am Vet
Med Assoc 192:798,1988.
5. Dyson S: Proximal suspensory desmitis: Clinical, ultrasonographic, and radio-
graphic features. Equine Vet J 23:25, 199I.
6. Devous MD, Twardock AR: Techniques and applications of nuclear medicine in
the diagnosisof equine lameness.J Am Vet Med Assoc 184:318,1984.
7. Pleasant RS, Baker GH, Muhlbauer MC, et al: Stressreactions and stressfractures
of the proximal palmar aspect of the third metacarpal bone in horses: 58 cases
(1980-1990).J Am Vet Med Assoc 201:19).8,1992.
8, Edwards RB, Ducharme NG, Fubini SL, et al: Scintigraphy for diagnosis of
awlsions of the origin of the suspensory ligament in horses; 51 cases(1980-1993). I
Am Vet Med Assoc 207:608,lqq5.
9. Spaulding K: Ultrasonic anatomy of the tendons and ligaments in the distal
metacarpal-metatarsalregion of the equine limb. Vet Radiol 25:155, 1984.
10. Nicholl RG, Wood AK, Martin IC: Ultrasonographic observation of the flexor
tendons and ligaments of the metacarpal region of horses. Am I Vet Res 54:502, 1993.
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.
12. Smith RK, Jones R, Webbon PM: The cross-sectional areas of normal equine
digital flexor tendons determined ultrasonographically. Equine Vet I 26t460, 1994.
as w e I as edge refracti onrel atedto the
Li garnent,
contai ni ng the hypoechoilcesi on,i s outl tnedi n w hi te.C ,
di gi talfl exortendon;V vessel s.
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.
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.
15. Denoit JM, Busoni V Ultrasonographic anatomy of the accessoryligament of the
superficial digital flexor tendon in horses. Equine Vet I 3l:186, 1999.
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
Res 54;1797,1993.
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
thoroughbred racehorses. Am I Vet Res56:1265,1995.
18. Gillis CL, Poole RR, Meagher DM, et al: Effect of maturation and aging on the
histomorphometric and biochemical characteristicsof equine superficial digital flexor
tendon. Am I Vet Res 58:425. 1997.
19. Riemersma DJ, De Bruyn P: Variations ia cross-sectionalarea and composition of
equine tendons with regard to their mechanical function. Res Vet Sci 4l:7, 1986.
20. Birch HL, Mclaughlin L, Smith RK, Goodship AE: Treadmill exercise-induced
tendon hy'pertrophy: Assessment of tendons with different mechanical functions.
Equine Vet J Suppl 3Q:222,1999.
21. Wilson DA, Baker Gl, Pijanowski GJ, et al: Composition and morphologic features
of the interosseous muscle in Standardbreds and Thoroughbreds. Am J Vet Res
52:1,33,1991.
22. Miles CA: Ultrasonic properties of tendon: Velociry attenuation, and backscatter-
ing in equine digital flexor tendons. J Acoust Soc Am 99:3225,1996.
23. Miles CA, Fursey GA, Birch HL, et al: Factors affecting the ultrasonic properties
of equine digital flexor tendons. Ultrasound Med Biol 22:907, 1996.
24. van Schie ]T, Bakker EM, van Weeren PR: Llltrasonographic evaluation of equine
tendons: A quantitative in vitro study of the effects of amplifier gain level, transducer-
tilt and transducer-displacement.Vet Radiol Ultrasound 40:151, 1999.
25. Biller DS, Myer W: Ultrasound scanning of superficial structures using m ultra-
sound standoffpad. Vet Radiol 29:138,1988.
26. Wood AK, Newell WH, Borg RP: An ultrasonographic off-set system for examira-
tion of equine tendons and ligaments. Am J Vet Res 52:1945, 1991
27. Prgh CR: A simple method to document the location of ultrasonographically
detected equine tendon lesions. Vet Radiol Ultrasound 34:211,1993.
28. Dyson Sl, Arthur RM, Palmar SE, Richardson D: Suspensory ligament desmitis.
Vet Clin North Am Equine Pract II:I77,1995.
29. Wright IM, McMahon PJ: Tenoslnovitis associatedwith longitudinal tears of the
digital flexor tendons in horses: A report of20 cases.Equine yetl 3I:I2, 1999.
30. Lepage OM, Leveille R, et al: Congenital dislocation of the deep digital flexor
tendon associatedwith hypoplasia of the sustentaculum tali in a thoroughbred colt.
Vet Radiol Ultrasound 36:384, 1995.
31. Nyland TG, Mattoon JS: Veterinary Diagnostic Ultrasound. Philadelphia, WB
Saunders,1995.
32. ReefVB: Equine Diagnostic Ultrasound. Philadelphia, WB Saunders, 1998.
 The Metacarpophalangeal
ffi Ouestions
l. Tiue or False.The cortical thickness of the metacarpal/metatar-
sal bones of the horse is normally uniform on dorsal ind palmar/
plantar aspects,thus a thicker dorsal cortex is indicative of disease.
2. Tiue or False.On a lateral view, the distal end of the metacar-
pus of the horse is relatively straight and the distal end of the
metatarsus is curved.
3. Tiue or False.The length of small metacarpal/metatarsalbones
(MC/MT II & IV) is typically uniform on an individual horse.
4. True or False.The multiple linear bone edgeson the palmar/
plantar aspectof the equine metacarpal/metatarsalregion result in
"mach bands," which may be misdiagnosed as fracture lines.
5. True or False."Metacarpal periostitis" ("bucked shins") usually
causesperiosteal response on the dorsal aspect of the metacarpal
diaphysis and may be associatedwith visible cortical fractures.
6. True or Faise. Although splint bones is a name given to the
small metacarpal/metatarsal bones (MC/MT II & IV), splint lesions
is the name for damage of the interosseousligament between these
bones and the cannon (MC/MT III).
7. Small cortical bone (stress)fractures may be difficult to dem-
ffi CHAPTER
ffi22
= The Metacarpophalangeal
ffi .(Metatarsophalangeall
.r
Articulation
ffi Russell
RussellL. Tucker
Tucker Ronald
Ronald D
D. Sande
I Anatomy
The anatomic structures of the metacarpophalangeal (MCP) and
metatarsophalangeal(MTP) articulations are so similar that it is
difficult to differentiate the right from the left or the front from
the hind limb on unlabeledradiographs.The MCP or MTP articu-
lations are hinge joints formed by the distal end of the metacarpal
(or metatarsal) bone and the proximal end of the proximal pha-
lanx. The articular surface of the proximal phalanx is concaveand
has a sagittal groove opposing the sagittal ridge at the distal end
of the third metacarpal(MC III) or the third metatarsal(MT III)
bone. This ridge and groove divide the weight-bearing surfaceinto
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
the proximal sesamoidsand the intersesamoidean ligament. There
are two radii of articulation of the joint. The dorsal radius serves
the weight-bearingportion, and the palmar radius conforms to the
articulation with the proximal sesamoids.'It is the junction of
these radii of articulation that may be confused with pathologic
flattening of the articular surface.
*"Palmar(o)" is used throughout this chapter with
the understanding
that "plantar(o)" should be substituted if reference is being made to the
hindlimb.
(Metatarsophalangeal)
Articulation 25ig
onstrate or recognize. Because of this, it is helpful to recognize
"typical" Iocations. In metacarpal/metatarsalIII, what three sites
are most common?
8. On the palmar/plantar aspect of the limb in the metacarpal/
metatarsal region, erroneous diagnosis of fracture may occur with-
out careful attention to specific bone margins. The false appearance
of fracture lines is due to what visual phenomenon?
9. rv\rhatnormal structure near the mid-diaphvsis of MC/MT III
may be mistakenlor a fractureor lylic lesion?
10. Indistinct periosteal margins and flaring of the distal ends of
the small metacarpalor metatarsalbonesmay be causedby enlarge-
ment of what soft-tissue structure?
ll. From the palmar surface in the proximal metacarpal region,
what major structures would be encountered by an ultrasound
beam between the skin and metacarpal III? (In what order?)
12. What should be consideredwhen one is acquiring an ultra-
sound machine for equine tendon sonography?
13. What preparation is necessarybefore ultrasound can be used
as a diagnostic aid in equine lameness?
Answers begin on page 727.
The joint capsule attachments at the proximal end of the proxi-
mal phaianx are immediately periarticular with no redundani cap-
sule or recesses.The capsuleattachesto the distal end of MC III
or MT III at the periarticular margins. Dorsally, there is a large
recessthat extends proximally and forms a pouch that allows full
extension of the joint. There is a bursa interposed between the
extensor tendons and the dorsal joint pouch. The palmar joint
capsule extends proximal to the sesamoidsbetween the suspensory
ligament and MC III or MT III.I Ligaments associated*ltn tfr.
MCP and MTP articulations have been described, and are illus-
trated in Chapter 23,The Phalanges.
I Radiographic examination
The intent of the radiographic examination should be to adequately
visualize the articular and periarticular skeletal structures and the
adjoining soft tissues.The examination should include the proximal
interphalangeal joint and the distal ends of the metacirpal or
metatarsal bones. Identification markers recorded in the emulsion
are essentialin radiographic examination of the MCp or MTp
articulation; right versus left and front versus hind should be
clearly designated. If oblique views are obtained, it is crucial to
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
for which markers should be placed dorsally.'
Survey radiographic examination of the joint should include a
lateromedial,a dorsopalmaq and two oblique projections (dorsal
45-degreelateral-palmaromedialand dorsal 45-degreemedial-pal-
marolateral) with the limb bearing weight if possible. The survey
examination should precede any special radiographic projections
or contrast studiesof the joint. The lateromedialprojection should
be made with the primary beam centered at the articulation and
directed parallel to an imaginary line connecting the collateral
fossaeat the distal end of MC III or MT III. A true lateromedial
projection is essentialfor proper assessment of the sagittalridge of
distal MC III or MT III.a The dorsoplamar projection warrants
thoughtful positioning. Becausethe plane of the joint is at an angle
to the solar surface of the hoof, the primary beam is directed from
dorsoproximal to paimarodistal at approximately 30- to 4O-degree'
(dorsal 35-degreeproximal-palmarodistalview). This should result
in the projection of the proximal sesamoidsover the distal MC III
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
medial-palmarolateraloblique projectionsshould be a routine part
of the survey examination. These oblique views are necessaryto
view the abaxial aspectsof the articular surfaces,the periarticular
margins, and the proximal sesamoids.
Additional projections of the joint may be indicated according to
the information gainedfrom surveyradiographs.'Thelateromedial
projection during flexion is performed while the foot is held off
the ground as if the sole of the hoof were being visually inspected.
Alternate positions include variations in the degree of flexion and
flexed oblique views. These projections may provide better visual-
ization of subarticular surfacesat the dorsal aspect of distal MCIII
or MTIII, the proximal part of the proximal phalanx, and the
articular margins of the proximal sesamoidbones.6
The dorsodistal-palmaroproximal projection is made while the
limb is not bearing weight. In this study, a tangential view of the
articular margin of the distal MC III or MT III bone is created.
The foot is elevated on a block, and the limb is extended. The
primary beam direction is approximately 125 degreesto the axis of
the metacarpal or metatarsal bone.t The degree of flexion and the
angle of the primary beam determine the tangent of the joint
surface that is visualized.
The palmaroproximal-palmarodistal projection is used to visual-
ize the palmar articular surface of MCIII or MTIII and the proxi-
ma1 sesamoids.Positioning of the patient requires that the x-ray
tube be placed close to the horse's body. The limb should be
positioned as far caudal as possible, and the foot is placed on a
supporting tunnel containing a cassette.o Some magnification re-
sults from the use of this projection owing to the distance betrveen
the oroximal sesamoidbones and the film cassette.
The abaxial surfacesof the proximal sesamoidsmay be examined
by placing a cassettemedial or lateral to the joint. The x-ray beam
is then directed in a palmaroproximolateral-dorsodistomedial or
palmaroproximomedial-dorsodistolateral direction, respectively.s
Contrast arthrography of the MCP or MTP joint is sometimes
useful. Five to ten milliliters of water-soluble contrast medium
containing 300 to 400 mg/ml of iodine is adequate.Injection of
contrast medium should follow arthrocentesis and withdrawal of
an equal volume of synovial fluid. Injection is made into the lateral
pouch of the joint, proximal to the lateral sesamoidsand dorsal to
the suspensory ligament. The joint should be vigorously flexed,
extended, and massagedbefore radiography to distribute the con-
trast medium throughout the joint.
I Alternative imaging
I modalities
Ultrasound offers many advantagesin the evaluation of the soft
tissues surrounding the MCP or MTP joint and is frequently used
to complement radiographic examination. Portable ultrasound ma-
chines can be used to image the extensor and flexor tendons, the
suspensory and distal sesamoidean ligaments, and the s'yrrovial
lining and joint recesses. The normal sonographicfeaturesof the
MCP and MTP ioints havebeen described.e
In addition to conventional radiography, computed tomography
(CT) may be useful in selectedpatients to image the MCP or MTP
joint. Like radiography,CT is basedon x-ray absorptionby tissues;
however, the system is much more sensitive to attenuation differ-
encesand has excellent contrast resolution. The CT information is
displayedin tomographic slicesthat have superb radiographic detail
and eliminate superimposition of overlying structures. CT excels
in the evaluation of bones and is very useful in imaging complex
fractures and subchondral lesions in the MCP and MTP ioints.
Unfortunately, general anesthesiais necessary,and few veterinary
referral centers currently have accessto CT scannersthat are capa-
ble of imaging horses.
Recently, magnetic resonance (MR) imaging has been used to
joints.lo'rt A distinct advantageof MR is the exceptionalanatomic
and physiologic detail of both soft tissue and osseousstructures
(Ftg. 22-1A and B). Additionally, MR imaging is multiplanar.
MR examinations are commonly performed using several types
of acquisition sequencesto demonstrate different anatomic and
pathologic features.As with CT scanners,MR systemsare expensive
and require that horses are under general anesthesia,which limits
the availability to a few large referral centers with MR systems
adapted to equine imaging.
Radiographic i nterpretation
of diseases of the
metacarpophalangeal
(metatarsopha lan gea I l
articulation
]oint diseasein the horse is often associatedwith repeatedtrauma,
and, as with any species,the pithologic changesmay be characteris-
tic of the joint and of the function required of the horse. A
study of racetrack injuries in horses has provided an overview of
pathologic findings and pathogenesisof MCP or MTP joint dis-
ease.r2Lamenessand distension of a joint are the initial clinical
signs that typically precede the request for radiographic examina-
tion. The earliest signs of joint diseasemay remain obscure on
radiographs, as wear lines in the articular cartilage or synovial
hypertrophy are usually not recognized.Radiographsofthe contra-
lateraljoint may be obtained for comparison.Although pathologic
change is often bilateral, it is usually in different stagesof develop-
ment.
Joint effusion
foint effusion is usually a result of trauma, with degenerative
changes in the articuiar surfaces and joint capsule. Radiographic
signs include soft-tissue swelling and joint distention. With chronic
insults, dystrophic calcification of the periarticular soft tissuesmay
also be present.13
Villonodular synovitis
Villonodular synovitis is characterized by a firm, nonfluctuating
swelling at the dorsal aspect of the joint. The villonodular masses
arise from enlargement of the synovial vilii of the joint capsule
and are associatedwith repetitive trauma. The condition is usually
diagnosed by clinical signs, history, palpation, and ultrasound.
With time, the radiographic signs will include mild to severe
erosion of distal MC III or MT III at the region just distal to the
dorsaljoint capsuleattachment.r+r6 Periarticularbony proliferation
may be present(Fig.22-2). With arthrography,radiolucent,space-
 The Metacarpophal angeal
(Metatarsophal angeal)
A rt iculat ion 2G |

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).

Figure 22-2. Lateromedialradiographof a metacarpophalangeal joint with changesof

vi l l o n o d u l asry n o v i t is. l th e jo in t,e r osi onof boneat the dorsoproxi -
T h e r eis swe llin gd o r sa to
mal joint capsuJeattachmenr(arrowheads), and earlyevidenceof supracondylar lysisat the
palmarcortex (arrows).Bony proliferationis visibleat the proximodorsal periarticular
border
of the p r o x i m a l
p h a l a n x.
2 6 ,2 A P P E NDI CU L ASK
R EL E T O N -EOU IN E

occupying massesof the slmovial villus hlpertrophy can usually be

identified in the dorsal recessof the joint (Ftg. 22-3).

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).

Degenerative ioint disease

Degenerativejoint diseaseis a nonspecific term describing deterio-
rati,on of articular and periarticular structures' The pathologic
events culminate in degenerativehypertrophic osteoarthritis/
osteoarthrosis, regardless of the initiating causes or biochemical
alterations. It is a chronic disorder charactertzedby progressive
deterioration of articular cartilage that results in a radiographic
loss in joint space and by reactive changes in the joint margin
and caosule.t'
The first stagesinclude cartilage degeneration and formation of
wear lines that are characteristic of hinge joints. These wear lines
are grooves in the articular surfacethat are oriented parallel to the
direction of ioint motion. Cartilaginous fibrillation and erosions
form in the surface, and subsequentwear results in narrowing of
the ioint space. If reduction in the width of a joint space is Figure224- Dorsopalmar radiographwithchanges degenerative
of chronic
jointdisease.Thereis narrowingof the jolntspaceandformationof osteo-
phytesat thejointmargins(arrows).

confirmed on two radiographic views, there is little doubt that

cartilage thickness has been reduced. Progressiveloss of joint width
is a subjective finding and must be carefully assessedwith clinical
signs to determine its significance (Fig.22-a).
Radiographic signs of degenerativejoint diseaseare soft-tissue
swelling, narrowed joint space,and bone remodeling with lysis and
proliferation. These findings may occur in any combination. Joint-
capsule thickening may be suspectedbut is rarely visualized, even
on high-detail radiographs. Soft-tissueswelling results from hyper-
trophy and proliferation of other periarticular tissues.
In chronic arthritis, there is sclerosisor eburnation of subchon-
dral bone with loss of trabecular architecture as a result of erosion
of the overlying articular cartilage. Repetitive stress or trauma at
the joint capsule attachments results in enthesophyte formation
(Fig. 22-5). Similar, but not identical, are the periarticular bony
osteophytesthat form at the joint margins in responseto damage
to the articular surface(seeFig. 22-4).lt is important to recognize
that many joint disorders can progress to a common endpoint
having the stereotlpic features of chronic degenerativejoint dis-
ease.l2The initiating factors of degenerative joint disease may
be difficult or impossible to determine in the late stages of the
diseaseprocess.

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

Figure 22-6. Xeroradiograph of a horsewith cortisonearthropathy.

There
Figure 22-5. Lateromedialradiographof a horsewith chronicdegenerative
j o i n td i s e a s es, e s a m o id itis,a n dd e sm itis.T h e r eis g e n e r a lized soft-ti ssue
sw el l of the joint space.Coarsebonetrabeculae
is narrowing are indicative
of
demineralization in periarticular
of bone.Mineralization softtissuesistypical
of
i n g a n d j o i n t d i s t e ntr o nCh . r o n lco ste o ch o n d r afrl a ctu r e sa r e presentat the
cortisone
arthroDathv.
apicesof the proximalsesamoids(arrowheads). Degenerativebony prolifera-
tion is presena a l r fa ceo f th e p r o xim apl hal anxand at the
t t t h e d o r so p r o xim su
ioint capsuleattachmenton the dorsodistalsurfaceof MC lll (solidarrows).A
periarticularosteophyteis evident on the dorsal rim of the proximalphalanx
(openarrow).Other changesincludesupracondylar lysis, remodelingof bony margin of the sesamoidsand are discussedunder the section on
trabeculaein the proximalsesamoids,and bony proliferation at the attachments sesamoidbasilar fractures. Type I or II fragments have the highest
o f t h e d e e p s e s a m o id e a n lig a m e n tsa t th e p r o xim a lp a lmaraspect of the incidence in Standardbredsand were originally reported as avulsion
o r o x i m aol h a l a n x .
fractures.22'ttBecauseof the anatomic origins, symmetry of the
lesions and breed predilection, it has been reported that these

collapse of subchondral bone with mineralization in periarticular

soft tissue (Frg.22-6).

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

fragments are the result of osteochondrosis(Figs. 22-8 and,22-9).

These fragments are the subject of much controversy. Studies have
focused on radiography,2+'6etiology,t' heritability,'&'zethe effect of
patient size,30epidemiology't' t' surgicai treatment,33'34and progno-
sis.26
Osteochondrosis of the sagittal ridge of MC III or MT III
is usually diagnosed in young horses and occurs with variable
radiographic expression (Fig.22-10). Radiographic signs may vary
from small flattening to large excavationsof subchondral bone of
the sagittal ridge. Lesions are usually best visualized on flexed
lateral projectionsof the MCP or MTP joint. Detachedosteochon-
dral fragments may be found in close associationto the bone defect
or may be nestled in distant recessesof the joint.3s

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

Figure 22-1O. Lateromedialradiographof a flexed MCP joint with osteo-

Figure 22-8. Dorsal45-degreemedial-palmarolateral radiographof the VICP chondrosisof the sagittalridge of MC lll. Excavationof subchondralbone can
joint with a type ll fragment (arrows) ottginatingfrom the medial palmar be seen betweenthe arrows.A periarticular fragment is presentat the dorsal
em i n e n c eo f t h e o r o x i mapl h a la n x. proximalmarginof the proximalphalanx.
 (Metatarsophal angeal)
The Metacarpophal angeal A rticulat ion265

Figurc 22-11. Dorsopalmar radiograph

of a horsewithchronic
septicarthri-
tis. Thereis generalized
soft-tissue
swelling.Thejointspacehascollapsed, Figure 22-12. Dorsopalmar radiographof a horsewith a slabfractureof
andthereissevere erosionof subchondral
boneof theopposingjointsurfaces. the lateral
condyle
of MC lll. Somefracturelinesmaybe difficultto visualize
Bonyproiteratio'r onallpe'iart
is ev'denl cJlarsr"aces. Markeddisplacement
larrows). suchasthisis oftennotpresent.
of a fragment

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."

Periarticular chip fractures

Chip fractures are more common in racehorsesand occur equally
in the front limbs. They commonly arise from the medial or lateral
periarticular eminencesat the proximal dorsal rim of the proximal
phalanx.noAcute chip fractures may have sharp borders and angular
configurations. Chronic chip fractures undergo remodeling and
Figure 22-13. Lateromedialradiographof a horse with chronicdegenera-
ti ve j oi nt di sease.A n osteochondral (chi p)fracturei s pre s entat the dors al
periarticular rim of the proximalphalanx(solidarrowsl.A basilarosteochondra
fracture of the proximal sesamoid is evident (arrowheads). There ts bony
prol i ferati on at the attachmentof the deep sesamoi dea n l i gamentsat the
palmaroproximalborder of the proximal phalanx iopen arrow). Vtllonodular
erosi onof boneand supracondyl lar ysi sare apparent.
 F
1t

266 A P P E NDI CUL ASK

R EL E T O N -EOU IN E

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.

Figure 22-16. Dorsal 45-degreemedialpalmarolateral oblique view of a

desmi ti s,and fracturesof metac arpal
horsew i th chroni csesamol di tl s, l l and
F igurc 2 2 - 1 5 . P a l m a ro p r o xlm o la te r a l- d o r so d isto m er da ia d rlographof a l V ; the medi alproxi malsesamoi di s proj ected.D egenerati veremodel i ngi s
hoise with a periarticularfractureof the medial proximalsesamoid(arrows) presentwith tunnelng (arrowhead), cystic change(salidarrow),and an abaxial
T he f r a c t u r eo r i g i n a t e sa t a n a r ticu la rsu r fa cea n d e m e r g e sa t the abal i al faclure (openarraw).lnset. Note fracturesat the distalends of the MC ll and
s urf aceo f t h e s e s a m o t d . the N4ClV brrowd.
 The Metacarpophalangeal
Figure 22-17. Lateromedialradiographof the distal metacarpal/metacar-
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
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
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.
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
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
a l o n gt h e b a s i l a mr a r g in s.
as fracturesr2'22'23,27,4r
and are considered by some to be manifesta-
tions of osteochondrosis.zr'2+33,42,43
Fractures of the proximal sesamoids
Proximal sesamoid fractures are consistently of three types: apical,
mid-body, or basilar.tnSome may be found as osteochondral frag-
ments separatedfrom the sesamoidapex (apical fractures;seeFig.
22-5) or base (basilar fractures, see Figs. 22-9 and 22-13). Frac-
tures through the body of the sesamoidmay have a narrow cleavage
line, indicating that the suspensoryapparatus remains intact (Fig.
22-IM). Wide separationof sesamoidfragmentsusually indicates
bilateral sesamoid fractures and disruption of the fibers of the
suspensoryligament (seeFig. 22-14b. Hyperextensionof the MCP
or MTP joint is apparent if stressis applied to the joint or if the
limb is bearing weight with disruption of the suspensoryligament.
Abaxial fractures are detectedby using special radiographic pro-
jections. These fractures result from ar,rrlsionof bone by a portion
of the attachment of the branches of the suspensoryligament on
the medial or lateral abaxial aspects of the respective proximal
sesamoid (Fig. 22-15).
The prognosis of sesamoid fractures is correlated to the type of
fracture and damage to the associated structures. A review of
the clinical aspects of apicalaaand basilaras sesamoid fractures
is available.
Sesamoiditis
Sesamoiditisis indicated radiographically by bony proliferation on
nonarticular surfacesof the proximal sesamoids.a6 Linear or cystic
(Metatarsophalangeal)
Articulation 267
lysis may appear to penetrate the sesamoidfrom the abaxial surface
(Fig. 22-16). Sesarrroiditisis usually associatedwith degenerative
changein the suspensoryligament and degenerativeremodeling or
fracture at the distal ends of MC II or MT IV (see Fig.22-16).
Disuse atrophy of bone
Disuse atrophy occurs most rapidly in the proximal sesamoid
bones, but may also be recognized in the tubular bones as a
reduction in bone opacity. Tiabeculae within the bone become
large and coarse.This change occurs as a result of altered stressor
axial weight bearing and may not signify primary pathologic
changein the fetlock (Frg.22-t7).
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
the hor 'e. I Am Vet N l ed As s oc l 8l :2o4, 1982.
9. Denolx JM, ]acot S, Perrot P: Ultrasonographic anatomy of the dorsal and abaxial
a'pec tsof the equi ne [er l oc k .Lqui ne Vet | 28:54, l 9qo.
10. Martinelli MJ, Baker Gl, Clarkson RB, et al: Magnetic resonance imaging of
degenerativejoint diseasein a horse: A comparison to other diagnostic techniques.
Equine Vet J 28:410, 1996.
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.
12. Pool RR, Meagher DM; Pathologic findings and pathogenesisof racetrack injuries.
Vet Clin North Am [Eq Prac] 6:l-30, 1990.
13. Gillette EL, Thrall DE, Lebel JL: Carlson's Veterinary Radiology, 3rd ed. philadel-
phia, Lea & Febigea1977,p. 435.
14. Barclay WR White KK, Williams A: Equine villonodular synovitis: A case survey.
Cornell Vet 70:72, 1979.
15. Nickels FA, Grant BD, Lincoln SD: Villonodular slnovitis of the equtne metacar,
pophalangealjoint. J Am Vet Med Assoc 168:1043,1976.
16. van Veenendaal JC, Moffat RE: Soft-tissue masses in the fetlock joint of horses.
Aus Vet J 56:533,1980.
17. Petterson H, Reiland S: Periarticular subchondral "bone cvsts,, in horses. Clin
Orthopaedics62:95. I gbg.
18. HornofWJ, O'Brien TR, Pool RR; Osteochondritis dissecansofthe distal metacar-
pus in the adult racing thoroughbred horse. Vet Radiology 22:98, l91l.
19. Edwards GB: Interpreting radiographs. 2: The fetlock joint and pastern. Equine
Vet T 16:4, 1984.
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.
21. Foerner JJ,Barclay WP, Phillips TN, et al: Osteochondral fragments of the palmar/
plantar aspect of the fetlock joint. Proceedings of the 33rd Annual Meeting of the
American Associationof Equine Practitioners,1987,p.739.
22.
_Birkeland R: Chip fractures of the first phalanx in the meratarsal phalangeal joint
ofthe horse.Acta Radiol (Suppl) 319:73,1972.
23. Petterson H, Ryden G: Arulsion fractures of the caudoproximal extremity of the
first phalanx. Equine Vet J 14:333, 1982.
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)
6:66,1988.
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'
I. A radiological survey. Equine Vet J (Suppl) 16:42,1993.
26. Grondahl AM, Engeland A: Influence of radiographically detectable orthopedic
changes on racing performance in Standardbred trotters. t Am Vet Med Assoc
2 0 6 : 1 0 1 3 ,1 9 9 5 .
C. Should be centered over the diaphysis of MC III and the
exposuremade with the limb not supporting weight.
D. Should be made prior to making special projections or
contrast studiesof the joint.

27. Dalin G, Sandgren B, Carlsten J: Plantar osteochondral fragments in the fetlock
joints of Standardbreds: Result of osteochondrosis or trauma? Equine Vet J (Suppl)
16:62, 1993.
28. Grondahl AM, Dolvik NI: Heritability estimations of osteochondrosis in the
tibiotarsal joint and of bony fragments in the palmar/plantar portion of the meta-
carpo and metatarsoPhalangeal joints of horses.I Am Vet Med Assoc203:101' 1993'
29. Philipsson J, Andr6asson E, Sandgren B, et al: Osteochondrosis in the tarsocrural
joint and osteochondral fragnents in the fetlock joints in Standardbred trotters. II.
Heritability. Equine Vet I (Suppl) 16:38,1993.
30. Sandgren B, Dalin G, Carlsten J, et al: Development of osteochondrosis in the
tarsocrural joint and osteochondral fragments in the fetlock ioints of Standardbred
trotters. II. Body measurementsand clinical findings. Equine Vet I (Suppl) l6:48, 1993'
31. Grondahl AM: The incidence of bony fragments and osteochondrosis in the
metacarpo- and metatarsophalangealjoints of Standardbred trotters; A radiographic
study. Equine Vet Science 12:81. 1992.
32. Sandgren B, Dalin G, Carlsten J: Osteochondrosis in the tarsocrural .ioint and
osteochondral fragments in the fetlock joints in Standardbred trotters. I. Epidemiology'
Equine Vet J (Suppl) 16:31,1993.
33. Fortier LA, Foerner JJ, Nixon Af: Arthroscopic removal of uial osteochondral
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.
34. Copelan RW, Bramlage LR: Surgery of the fetlock joint. Vet Clin North Am llarge
Anim Practl 5:221, 1983.
35. Yovich IV. Mcllwraith CW, Stashak TS: Osteochondritis dissecansof the sagittal
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 .
36. Zekas LJ, Bramlage LR, Embertson RM, et al: Characterization of the type and
location of fractures of the third metacarpal/metatarsal condyles in 135 horses in
central Kentucky (1986-1994). Equine Vet J 31:304, 1999.
37. Rick MC, O'Brien TR, Pool RR, et al: Condylar fractures of the third metacarpal
bone and third metatarsal bone in 75 horses: Radiographic features, treatments, and
outcome. I Am Vet Med Assoc 183:287,1983.
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 .
2. Villonodular spovitis of the MCP or MTP joint is usually
A. The resultof low-gradeinfection.
B. A sequelto osteochondritisdiseccansand some nutritional
disturbances.
C. The result of repetitive trauma.
D. Occurs with degenerative joint diseaseand cartilagedegra-
dation.
joint
3. Lateromedialprojection of the left metacarpophalangeal
of a 2-year-old Thoroughbred filly that presented with front limb
joints (Fig. 22-
lamenessand swellingat the metacarpophalangeal
18). Give the radiographicfindings, diagnosis,and suggestionsfor
additional radiographicexamination.
4. Fractures that communicate with the MCP or MTP joint
A. Are most common at the medial condyle of the right
metacarpusin young, racing Thoroughbreds.
B. May involve any of the bony components of the fetlock
joint.
C. Are usually exerciselimiting but not prohibiting.
D. Always result in crippling lameness.
5. Supracondylar lysis of the metacarpus or metatarsus is
A. Similar to villonodular synovitis except that it occurs at the
palmar (plantar) surfaceof the bone.
B. Diagnosedmost easilyusing contrast arthrography.
C. Is commonly seenas a sequelto cortisoneinjections.
D. Is a common sequelto septicarthritis.
6. A 6-month-old Appaloosafilly presentedwith an open, drain-
ing wound dorsal to the fetlock (Fig.22-19). List the radiographic
findings and diagnosis.

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.

40. Yovich JV Mcllwaith CW: Arthroscopic surgery for osteochondral fractures of

the proximal phalanx of the metacarpophalangeal and metatarsophalangeal (fetlock)
joints in horses.I Am Vet Med Assoc 188:273,1986

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.

42. Barclay WR Foerner ]J, Phillips TN: Lameness attributable to osteochondral

fragmentation of the plantar aspect of the proximal phalanx in horses: 19 cases
( 1 9 8 1 1 9 8 5 ).I A m V e t Me d Assoc 191:855,1987.

43. Grondhal AM: Incidence and development of ununited prorinoplantar tuberosity

ofthe proximal phalanx in Standardbred trotters. Vet Radiol Ultrasound 33:18,1992'

44. Spurlock GH, Gabel AA: Apical fractures of the proximal sesamoid bones in 109
Standardbredhorses.I An Vet Med Assoc 183:76,1983.

45. Parente EJ, Richardson DW, Spencer P: Basal sesamoideanftactures in horses: 57

c a s es(1 9 8 0 -1 9 9 1 ).I A m V et Med Assoc202:1293,1993.

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.

Figure 22-19
7. Degenerativejoint diseaseof the MCP or MTP joint
A. Can bestbe diagnosedby radiographicsignsofperiarticular
bone proliferation and subchondralbone remodeling.
B. Is, most often, a sequelto septicarthritis.
C. Is a nonspecific term for progressivedeterioration of all
tissuecomponentsof the joint.
D. Is a specific joint diseaseresulting from repetitive trauma.
8. Osteochondrosisof the MCP or MTP joint
A. Is diagnosed more frequently in the proximal sesamoids.
B. Has clearly defined heritability.
C. Is often diagnosed in Standardbredsat the proximal
palmar/plantar margin of the proximal phalanx.
D. Has been mistakenly diagnosed as traumatic avulsion of
apophysesand fractures of the sagittal ridge of MC IIL
projection of the left MTP joint
9. A dorsomedial-plantaroiateral
CHA P TER
23
The Phalanges
r ElizabethA. Riedesel
Radiographic examination of the equine phalanges is most fre-
quently performed as part of the diagnosticevaluationof lameness
or of firm or persistent swellings,or during a pre-purchaseexami-
nation. History and physical examination findings should indicate
a high likelihood of lesion in the pasternor foot. Diagnosticnerve
The Phalanges 269
Figure 22-2O
of a 2-year-old Standardbred gelding was obtained (Fig. 22-20).
Describe the radiographic findings and give your diagnosis.
10. Diseaseof the proximal sesamoids,referred to as "sesamoi-
ditis,"
A. Acquire the name because,with the exception of fractures,
most diseasesresult in inflammation and irritation of the
periosteum.
B. Is often associatedwith changesin the suspensoryligament
and tissuessurrounding the fetlock joint.
C. Is an inflammatory diseaseof the bone that leads to degen-
erative joint disease.
D. Results in separation of the bone owing to progressive
weakeningand avulsion of the supporting ligamentous
structures.
Answers begin on page 727.
blocks are used to localize the origin of pain more specifica1ly,
especiallyin the horse with multiple abnormalities identified dur-
ing the physical examination.r The significance of many of the
radiographic abnormalities of the equine phalanges is difficult to
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

Fi gure 23-1. A , Th e c entral and

collateralsulci of the foot have been
packedw i th a pl i abl em ateri aof s i m-
l ar radi opaotyas the s ol e [Pay D oh].
B, Dorsal65-degreeproximal-palmaro-
di stalvi ew of a norma ldi s talphal anx
w i th the sul ci packed.N ote the good
defi ni ti onof vascul ar channel w s i thout
superi mposed ai r arti fa c ts .

history and physical examination are correlated with the radio-
graphic findings.
I Technical factors
Patient preparation
Dirt, skin lesions,and iodine-containingmedicationscan all pro-
duce opacities that complicate radiographic interpretation. Conse-
quently, the patient should be examined ciosely to ensure that all
such material has been removed from the hair coat and hoof wall.
Shoesand any additional pads should be removed so that optimal
radiographs of the distal phalanx can be obtained. The sole and
sulci of the frog should be thoroughly cleaned with a hoof pick.
The sulci may then be filled with a material of soft-tissue opacity
(such as Play-Doh, Rainbow Crafts, Cincinnati, OH) to the level
ofthe solar surface(Fig. 23-IA). Packingthe central and coliateral
sulci eliminates radiolucent linear shadows created when the air-
filled sulci become superimposed on the distai phalanx in the
dorsal 65-degreeproximal palmarodistal* oblique view (see Fig.
23-18).
Recommended views
The eouine foot is structured such that certain anatomic areascan
be imaged as a group. Thesegroupingsand the projectionsneeded
*Palmar(o) is used throughout this chapter with the understanding that
plantar(o) should be substituted if referenceis being made to the rear digit.
to evaluate them optimally are listed in Table 23-1. Excellent,
complete descriptionsof patient positioningt't are available,and
the reader is referred to these sourcesfor additionai information.
I Normal radiographic anatomy
I (including variations)
Osseousstructures
Normal radiographic anatomy is illustrated in Chapter 50, as well
as in other published sources.a'sHowever, severalvariations in the
appearanceof the anatomic structures are worthy of mention.
These variations are frequently misinterpreted as abnormal. A nu-
trient foramen occurs as an inconsistent radiographic finding in
the proximal phalanx of approximately 87o/oof Thoroughbreds and
Standardbredsthat are at least I year of age.u,tWhen present,these
foramina are sometimes bilaterally symmetrical and can be located
in the palmar or dorsal cortex. No horseswere identified in those
surveys to have both a dorsal and a palmar nutrient foramen;
however, the author has noted both to be present in several foals.
When present in the dorsal cortex, the foramen is typically seen in
a lateromedial view as a radiolucent line running obliquely proxi-
mal to distal through the mid-diaphysealcortex (Fig. 23-2). In a
dorsopalmar view, it appears as a thin lucent line within the
medullary region. When in the palmar cortex, the foramen is
located in the distal third and courses in a shorter oblique-to-
transversedirection. Of greatestimportance is that these foramina

Table 23-1. Views for equine phalanx evaluation

Examination Structures evaluated Views

Pastern Pr ox im alphalanx D o r s a l4 5 - d e g r e ep r o x i m a l - p a l m a r o d i s t ao lb l i q u e
joint
Pr ox im alint er phalangeal Lateromedial
M iddle phalanx D o r s a l3 5 - d e g r e el a t e r a l - p a l m a r o m e d i o abl lique
D o r s a l3 5 - d e g r e em e d i a l - p a l m a r o l a t e r o abl lique
D istalph ala nx Dis t alphalanx D o r s o p a l m a rw i t h h o r i z o n t a lb e a m a n d d o r s a l 4 5 - d e g r e ep r o xi m a l -
p a l m a r o d i s t aol b l i q u ew i t h h o r s e s t a n d i n go n c a s s e t t e
joint
Dis t alint er phalangeal D o r s a l6 5 - d e g r e ep r o x i m a l - p a l m a r o d i s t ao lb l i q u ew i t h h o r s e sta n d i n g
on cassette
L a t e r o m e d i a lw, i t h f o o t o n b l o c k s o a s t o i n c l u d es o l a r m a r gi n o f d i sta l
p h a l a n xa n d s o f t t i s s u e so f s o l e o n t h e r a d i o g r a p h
Two oblique views: dorsal 65-degreeproximal,45-degreelateral-
p a l m a r o d i s t o m e d i aal n d d o r s a l6 5 - d e g r e ep r o x i m a l 4 5 - d e g r e em e d i a l -
p a l m a r o d i s t o l a t e r aOl . b l i q u e sa r e e s p e c i a l l yu s e f u lw h e n d i sta l
phalanxfractureis suspected

Figurc 23-2. Radiolucent linesare visiblein boththe dorsaland palmar
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.
should not be mistaken for fractures. Variability in the location of
the nutrient foramen of the hindlimb proximal phalanx has not
been reported. Variations have not been reported in other breeds,
but they very likely occur.
Variations may also occur in the appearanceof trabeculae in the
medullary cavity of the proximal phalanx (Fig. 23-3). A prominent
radiolucent center in the medullary cavity surrounded by a ringlike
radiopacity is illustrated in Figure 23-38; this is a normal variation
in trabeculation and does not indicate cyst formation.
If the lateromedial view is slightly oblique, two normal structures
become more prominent and can be misinterpretedas abnormal.
The first is the ridge for the V-shaped attachment of the oblique
sesamoideanligament along the palmar cortex of the proximal
phalanx. The second is the eminence for attachment of the collat-
eral ligaments of the distal interphalangeal joint along the dorsum
of the middle phalanx.
The radiographic appearanceof the normal distal phalanx varies
in severalrespectswhen depicted in the dorsal 65-degreeproximal-
palmarodistal oblique view8 10The most obvious differencesare in
the number and distribution of vascular channels. The number of
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
the periphery, some give rise to secondary branches that reach the
solar border. Although this branching pattern is unique to individ-
ual animals, the major channels identified at the solar margin
should communicate with the solar canal. In Figure 23-4, some
variations in the number of vascular channels and the distribution
and patterns of radiation from the solar canal are illustrated.
A smoothly rounded concavity in the toe of the distal phalanx
may be seen in the normai horse. This notch is referred to as the
crena margins solearisor, more commonly, the crena or toe notch.
In a radiographic study of the foredigit of the developing Quarter
horse, a crena was identified in foals between 4 and 22 weeks in
The P halanges271
83o/oof the distal phalanges followed.', The depth of this notch
usually does not exceed 1.5 cm.e The crena is more prevalent in
front than in hind feet.8Ninety percent of sound racing Thorough-
breds have bilateral symmetry in the presenceof the crena in the
front feet, 5oloasymmetrically in the front feet, and 570 in neither
front foot.Io
The shape of the extensor processof the distal phalanx may also
differ among individual animals (Fig. 23-5).8 The margin of the
normal process,however, should be smooth regardlessof its shape.
The palmar processesof the distal phalanx become more exten-
sively ossified with age. The morphologic development of the
palmar process has been described in the foal (3 Io 32 weeks of
age).t'Comparethe palmar processes of the three horses(5 months
old, B years old, and 15 years old) in Figure 23-6.
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
more opaque soft-tissue band as it passesbetween the level of the
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
extent of the hoof wall is not alwavsclearlv distinct in lateromedial
and dorsopalmar views. The ergot .i.rt" a radiopacity when
superimposed on the proximal phalanx -uy in the dorsopalmar view
(seeFig. 23-38). In the lateromedial view, the ergot opacity can be
seen along the palmar surface of the skin.
Articular cartilage and collateral cartilages
The properly positioned dorsal 45-degree proximal palmarodistal
view is the best view for evaluation of the width of the metacaroo-
phalangeal, proximal interphalangeal, and distal interphalangeal
joints. In the normal foot, the metacarpophalangealjoint is usually
the narrowest of these articulations, the proximal interphalangeal
joint is slightly wider, and the distal interphalangeal joint is rhe
widest (see Frg.23-3A). If the horse is not bearing weight evenly
on the leg, the asymmetrical loading forces can cause the appear-
ance of narrowing of the loaded side and widening of the non-
Ioaded side of the joint (see Fig. 23-l2B). This artifact can be
recognizedbecauseit similarly affectsall three joints. The collateral
cartilages are not visible as independent shadows in the normal
I Radiographicchanges caused
I by diseasesof the phalanges
General comments
The common diseasecategoriesthat affect the phalangesand asso-
ciated joints are acute trauma leading to fracture, chronic repetitive
trauma leading to enthesopathyand degenerativejoint disease,and
infection. Inflammation of the laminae of the hoof wall (laminitis),
leading to a disturbanceof the mechanicalsupport of the foot, is
the only common effect initiated by metabolic disease.Neoplasia
of the soft tissuesor phalangesis extremely rare.
272 A P P E NDI CU L ASRKE L ET ON -EOU IN E

iial

Figure 23-3. Dorsopalmarview of two normal

equi ne proxi ma phal anges.A , N ote the normal
thi cknessof the l ateraland medi alco rti c esof the
proxi malphal anxat the i uncti onof the mi ddl eand
di sta one thi rdof the bone.The radi ol uc ent medul -
larycavityis seen betweenthe thickestpartsof the
cortex.The w i destj oi nt spacei s usu al l ythe di s tai
i nterphal angeal j oi nt,w i th the j oi nt spac esbec om-
ing progresslvely more narrowtoward the metacar,
pophal angeal nt.B , A thi n ri m of opaquetrabec u-
j ol
ati onsurroundsthe centralmedul l arv c av i tvof the
proximalphalanxlsolld arrow). fhe ergot is elon-
gated n rl ^i s ani maland i s seen be c aus eof i rs
summationwith the proximalphalanx(openarrow).

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 .)

Figure 23-6. Palmarprocessesof the normaidistalphalanx

i n the horsebecomemore extensi velossiy fi edw i th age. Lat-
eromedialviews of A, a s-month-oldfoal; B. an 8-vear-odStan-
da'db'ed;C , a 15-vear-olAdrabi ancross-breed.
2 I4 A P P E NDI CU L ASK
R EL E T O N -EOU IN E

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.)

The followinganatomickey is designedfor Figures23--7and 23-8

A , T h i r dme ta ca r p ablo n e . 12. Metacarpophal angeal j oi ntcapsul e(bl ended w i th fi bers
B . P r o x i m ase l sa m o idb o n e . from the commondi gi talextensortendon).
C . P r o x i m apl h a la n x. 13. D i stalpal marrecessof the metacarpophal angeal j oi nt.
D . M i d d l ep h a la n x. 14. D orsalrecessof the proxj mali nterphal angeal l oi nt
E. Distap l h a la n x. capsui e.
l sa m o id{ n a vicu labr )o n e .
F . D i s t a se 15 P al marrecessof the proxi mali nterphal angeal j oi nt.
1 . C o m m o nd ig itael xte n so te r ndon. 16 P roxi mali nterphal angeal j oi ntcapsul e(bl ended w i th
2. Extensorbranchof the interosseous(suspensory) fibersfrom the common digitalextensortendon).
ilgamenr. 1 7 D orsalrecessof the di stali nterphal angeal j oi nt.
l xte n so te
3 . L a te r adl ig ita e r ndon. 1 8 P al marrecessof the di stali nterphal angeal j oi nt.
4 . I n t e r o sse o u(ssu sp e n so r y)lig a m e n t. 1 9 C ol l ateral
sesamoi dean l i gament.
5 . S u p e r ficiadlig itafle
l xo rte n d o n . 20 D i stalsesamoi dean i mparl i gament.
6 . D e e pd ig itafle l xo rte n d o n . 2 1 P odotrochl ear bursa.
m e ta ca r p alig
7 . S u p e r ficiatrl a n sve r se l a m e n ipal
t mar 22 Medi alcol l ateralIi gamentof the metacarpophal angeal
a n n u la lig
r a m e n t) . Joi nt.
8 . P r oxim adl ig itaal n n u la ligr a m e n t. 23 Lateralcol l aterall i gamentof the proxi mali nterphal angeal
9 . S u p e r ficiaistr se sa m o id e alig
l a lg h t) n a m e n t. l ornI.
' 1 0 .M i d d le( o b liq u ese
) sa m o id e align a m e n t. 24 Medi alcol l aterall i gamentof the di stali nterphal angeal
1 1. D e e p( cr u cia tese ) sa r r o id e alig
n a m e n l. l ornt.
 The P halanqes275

9
22
11

Figure 23-9. Lateromedialview of the metacarpophalangeal 1oint.Smal]

chi p fragmentsfrom the dorsoproxi mal edge of the pro x i malphal anxare
evident /open arrow).There is also oerlostealoroliferation.corticalsclerosis
(curvedarrow), and avulsionfragmentationor dvstrophiccalcificationof the
'nse'ri oro{ the l areraldi g;Lai
extensorte'toor.

Figure 23-8. Palmarview of the sesamoideanandcollateralligamentat-

tachments Keyin egendIor Fig.23-7.)(lllustration
of thedigit.lSeeAnatomtc
A. Sl'ook.
bv Bichard DVM.)

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
mistaken for dystrophic mineralization of soft tissue.
Decreasedopacity within the soft tissues is associatedwith the
presenceof air or gas in the subcutis or the fascial planes of the
tendons and ligaments. Soft-tissue gas commonly follows diagnos-
tic nerve block and open skin wound but rarely is causedby a gas-
producing organism.
The radiographic signs of abnormal bone tissue include alter-
ation of contour, margination, and opacity. These signs are caused
by a combination of new bone formation and bone removal.
Repeatedpatterns of bone change tend to be associatedwith spe-
cific injury to the phalanges and associatedjoints. Figures 23-11
and,23-12 depict the variable appearancesof the periosteal surface,
joint space,and subchondral bone that occur in the more common
diseasesof the phalanges.
Strain and sprain iniuries
Projectionsor bumps of bone are commonly seenon the cortical
surfaces of the phalanges, especially in the proximal and middle
phalanx. Many of these are caused by strain and sprain injuries.
Strain injury results from damage to muscle or tendon induced by
overuse or overstress.3In its mildest form, strain causes only
inflammation. With chronic repeated strain or more severeacute
strain, disruption within the soft-tissue unit or avulsion from its
bone attachment occurs. Radiographically, the swelling of inflam-
mation in the tendon may not be particularly evident. Soft-tissue
changes are best imaged using ultrasound. Although it uncom-
monly occurs, dystrophic mineralization can develop in the chroni-
cally inflamed tendon. Radiography is useful for assessingthe bony
attachment sites of the tendons. Thus knowledge of the attachment
sites of the flexor and extensor tendons on the phalangesis needed
(see Figs. 23-7 and 23-8). Avulsion fracture at the attachment site
can occur and will be evident as a bone fragment displaced in the
direction of traction of the tendon. New bone formation when
Figure 23-11- Variableappearanceof contour and opacity of periosteal
bone proliferation-andlikely causes:A, Normal cortex. 8, Smooth margin,
mildly opaque-recent subperiosteaihemorrhagefrom direct trauma or exu-
date of infection.C, Smooth margin,opaque-inactive,remodeledtrauma D,
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
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,
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
S ho o k .D V M . )
seen early in its formation at one of the attachment sites will likely
be minimal in volume and have a mildly irregular surface. If the
strain injury continues, the new bone production enlarges and
continues to have a ftrzzy irregular margin. Such a change is
occasionally seen at the insertion of the lateral digital extensor
tendon, on the dorsolateral proximal surface of the proximal pha-
lanx (see Fig. 23-9). In other instances of chronic strain affecting
an attachment site, the thickness of the new bone (enthesophyte)
increasesand takes on a smooth, hook or spurlike shape,projecting
in the direction of tension or traction. Radiographically aging or
determining the activity ofthese bone changesis diffrcult. Periosteal
new bone formation is typically not visible until 5 to 7 days (foal)
or 10 to 14 days (adult) following stimulation. When a prominent
smooth enthesophyteis seen on a first radiographic evaluation of
a horse, it should be taken as a signal of strain injury that occurred
at least 5 to 6 weeks oreviouslv.
Sprain injury resulis from iu-ug. to the supporting ligaments
of joints induced by movement of the bony components beyond
their normal range.' Similar to strain injury, the mild sprain injury
causes inflammation that is not likely to cause visible changes
radiographically. Greater degreesof injury result in loss of stability
to the joint, allowing complete or partial luxation. Stress views
may be needed to detect subluxation. Laxity in a subluxated joint
is often more apparent at physical examination than at radiography,
especially if the horse is unwilling to bear full weight on the leg.
Conversely, complete luxation is typically evident and may be
accompanied by avulsion fractures at the ligament insertion sites.
Larger fractures of the phalangesmay also be associatedwith joint
luxation. This is commonly seenwith comminuted fractures of the
middle phalanx and associatedloss of congruency of the proximal
interphalangealjoint (seeFig. 23-15). Secondarychangesexpected
with subluxation are enthesophlte formation at the ligament inser-
tion sites and some degreeof degenerativejoint disease.The range
of change will depend on the severify of the initial injury and the
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
dorsal plane to the long axis of P1. Figure 23-13 illustratesthese
fractures of the proximal phaianx. Several retrospective surveys of
Thoroughbred and Standardbred racehorseswith these types of
fractures have been reported with an attempt to correlate fracture
configuration to prognosis.l6'17'le 22The most frequently reported
fracture configuration in these breeds is the noncomminuted, in-
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. It occurs in both front- and hindlimbs of these breeds.
However, reported fractures are somewhat more common in the
front limbs of Thoroughbreds and the hindlimbs of Standardbreds.
This fracture tl?ically originates at the proximal articular surface
just lateral to or within the midline plane of the sagittal groove
(Figs. 23-lM; see also Fig. 23-l3A). Very few originate medial to
the midline plane.
Two variations of the noncomminuted, incomplete, monoarticu-
lar sagittal fracture occur. The short (<30-mm;xtension into the
diaphysis) variation is slightly more common than the long (>30-
mm extension into the diaphysis) variation. Both fractures may
course in a slightly spiral or oblique manner. This effect is depicted
as two parallel or "offset" radiolucent lines representingthe fracture
plane in the dorsal and palmar cortices. The short fracture may be
more difficult to identify on an initial radiographic evaluation.
Both variations of fracture are seenonly on dorsopalmar views. As
there is typically very little gap to the fracture plane, the x-ray
beam must pass parallel to the fracture line to detect the fracture
gap. Repeatradiographs in 7 to 10 days should allow identification
of the fracture more readily, after lysis of bone along the fracture
edgeshas occurred during the first stagesof healing. When imaging
occurs several weeks after the onset of lameness, periosteai new
bone will likely be presenton the dorsal or palmar surface,indica-
tive of bony callus. At this stage, the new bone is visible on the
Iateromedialview the fracture line on the dorsopalmar view should
be less visible, and sclerosisin the adjoining bone should be seen.
Horses with either the short or the long variation of the non-
comminuted, incomplete, monoarticular sagittal fracture have a
good prognosis for survival and return to athletic performance.
However, in a survey of Standardbreds, these horses had slower
racing times and decreasedperformance indices (order of finish
times purse) regardlessof fracture length or medical versus surgical
treatment.22This type of fracture is not mentioned in a report of
diagnosis and treatment of Quarter horse racehorses.2l
_Noncomminuted, complete sagittal fractures of the proximal
phalanx occur with considerablylessfrequency than do incomplete
fiactures in racehorses.This type of fracture is, however, reported
to be more common in the Western performance horseJ Two
variations of this fracture occur: one ii biarticular involvine its
origin at the metacarpophalangealjoint and its exit at the proximal
interphalangealjoint; the other is monoarticular and exitslypically
through the lateral distal palmar or plantar cortex (see nigs. ZZ-LZA
and 23-l4B). These fractures are most readily seen in ihe dorso-
palmar_view. Although these horses have a good prognosis for
survival with conservative or surgical treatment, prognosis for
rcturn to an equal level of performance is more guarded than with
the noncomminuted, incomplete, monoarticulai sagittal fracture.
Significantly fewer racehorseswith fracture into the proximal inter-
phalangeal joint havereLurnedto racing.ro
Comminuted fractures of the proximil phalanx (seeFig. 23-l3C)
accounted for approximately 30o/oand 160/oof proximal phalanx
fractures, not including dorsal proximal chip fractures, in two
surveysof large numbers of horses.r7,2r The maiority of Thoroush-
bredsin one surveywere 2-year-olds.r'Theaverageage ofhoises
in- another survey was 8.3 years (range,2 to 22 years).ttVariations
of this tlpe include comminution throughout the phalanx; only in
the proximal portion; or only in the distal portion. Frequently,
these fractures have one exit throuqh the lateral rather than the
medial cortex. Thesefractures are typ'ically biarticular and are more
likely to be complicated by being open. The multiple fracture
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
and dorsopalmar views. Oblique views should also be taken to
obtain a more thorough depiction of the fracture configuration.
Comminuted fractures have the most guarded prognosis for sur-
vival and very poor prognosis for return to athletic performance.
Much lesscommonly reported are incomplete or complete dorsal
plane fractures that originate at the Proximal articular surface
(see Fig. 23-l3B).w' 20'24These fractures may be detected only on
lateromedial views. The incomplete fracture typically courses dis-
tally toward the dorsal cortex. The complete variation either breaks
through the dorsal cortex or extends the entire length of the
phalanx to exit in the proximal interphalangeal joint. The latter
variation tlpically splits the proximal phalanx into roughly equal
dorsal and palmar or plantar halves. Other sporadically reported
fractures of the proximal phalanx include physeal fractures (typi-
cally Salter-Harris II) and incomplete distal articular fractures.lT
Middle phalanx
Fractures of the middle phalanx (P2) include comminuted fracture
(most common), fracture of the plantar or palmar proximal emi-
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)
ti cul ar; i 4) C ompl ete,bi arti c ul ar.B ,
nnrcAl nlana fra.t lrraq-nOn-
commi nuted:(1) C om pl ete,monoar-
ti cul ar; (2) C ompl ete,bi arti c ul ar.C ,
C ommi nuted,complete, bl arti c ul ar,
dorsaland/orsagi tta lpl ane. Mi ddl e
phal anx: D , P al may ' pl antar emi nenc e
VII (monoarticular, complete);F, Commi-
nuted, compl ete, bi arti c ul ar.D i s tal
phal anx: E {l ) N ona rti c ul ar,pal mar/
pl antar process; {l l) A rti c ul ar, ex -
tendi ng from di stal interphal angeal
j oi ntto sol armargi n;(l l l )A rti c ul ar, mi d-
sagi ttal , di vi des i nto equal parts ;
(lV)Articular,extensorprocess; Ar- (V)
ticular,comminutedbody fracture(not
of types l l , l l l , or l V );(V l )S ol armargi n;
i V l l ) S ol ar border of pal mar/pl antar
processi n foal s.
nence (both medial and laterai eminences-common; single
sminslsg-uncommon), and osteochondral chip fracture (rare)
(Fig. 23-15; see also Figs. 23-I3D and E). Physealfracture can
occur in the skeletally immature horse but is reported very infre-
quently. The comminuted (complete and typically biarticular) and
eminence fractures (complete monoarticular) are most common in
horses whose activity subjects the middle phalanx to an extreme
combination of simultaneous comoression and torsion forces while
the foot is fixed to the ground." Thus these types of fractures are
most common in working or performing Western horses, polo
ponies, and jumpers. For both common fractures, the hindlimbs
are reported to be involved approximately twice as frequently as the
front limbs.'zs2eHowever, the front limb is more equally affectedby
comminuted fracture. The hindlimb is considerably more fre-
quently reported to have a plantar eminence fracture without
other comminution. Neither type of fracture is difficult to identify
radiographically. When the eminence is fractured without commi-
nution, the fragments are variably displaced in a plantar direction.
 The P h alanges279

F
p,

. ;,r;.1
,.ultlruuitll
iiuu,:i119u

;"i
""l
::

Figure 23-14. Incomplere/Ai and complere iBl

s a g i t t aflr a c t u r eo f t h e p r o xim apl h a la n x.
T h e p la n eo f
t h e p r i m a r yx - r a yb e a mm u st b e p a r a lleto l th e fr a ctu r e
p l a n et o i d e n t i f yt h i s le sio nwh e n n o fr a g m e n td ls- I .l
1
p l a c e m e nits o r e s e nt.

In the worst cases,the proximal interphalangealjoint is simultane-
ously luxated, allowing the distal end of the proximal phalanx to
descenddistally and override the middle phalanx. As the proximal
articular surface of the middle phalanx is involved in this fracture,
successfulrepair of this fracture typically includes arthrodesis of
the proximal interphalangealjoint. Prognosisfor survival with such
repair is good and for return to usablesoundnessis fair to good.262s
Comminuted fractures can involve only the proximal portion of
the middle phalanx, but more commonly, the fracture planes ex-
tend into the distal interphalangealjoint. Decision to tre;t and the
type of treatment of the comminuted middle phalanx fracture
dependon many factors;however,one of the mosiimportant is the
degreeof involvement of the distal interphalangealjoint. Additional
oblique views at different angles compared with the standard (see
pastern examination, Table 23-l) may be needed to fu1ly identif.
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

td improve assessment of the degreeand configuration of commi-

nution.'5 Using computed tomography, the number of fracture
planes was found to decreasetoward the distal end of P2. Of
the reported horses having middle phalanx fractures, those with
comminuted fractures were most likely to be euthanatized at the
time of diagnosis or euthanatized during the course of postsurgical
healing because of continued lameness."' 26'2e Yet, many of the
horses successfullyrecover to reach breeding or athletic soundness.
Secondary degenerativejoint diseasein the distal interphalangeal
joint may significantly complicate long-term recovery for return to
athletic performance.

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 .

Figure 23-18. A palmarprocessfracturein the distalphalanxof a foal (TVpe
V l l i n F i 9 .2 3 - 1 3 F ) . Th ea r r o wsin d ica tea r a d io lu ce nlin
t ee xtendi nqfrom the
i n c i s u r eo f t h e p a l m a rp r o ce ssto th e so la rm a r g in .
I Infection
Osteomyelitis and septic osteitis
Infection of the phalangesresults most commonly from trauma or
as a complication of surgical treatment, and less commonly as the
result of hematogenous dissemination of bacteria. Lacerations and
puncture wounds by foreign objects carry a high risk of secondary
infection ofthe soft tissueand bone. Sequestrumformation associ-
ated with bacterial infection is likely associatedwith a currently or
periodically draining soft-tissue lesion. Sequestra vaty widely in
length and thickness. Oblique views may be necessaryto profile
the sequestrum.The periosteal new bone associatedwith a seques-
trum may be smooth or mildly irregular (Fig. 23-19).
Septic (infective) pedal osteitis refers to infection of the distal
phaianx. Common radiographic changesare discrete areasof lysis,
irregular margin, and decreasedopacity of P3, typical of chronic
inflammation. Gas may or may not be present in the soft tissue
adjacent to the surface of P3. A pathologic fracture is uncommon.
..-*
'l
F i g u r e 2 3 - 1 9 . S e q u e str u mfo r m a tio nin vo lvin gth e
pr o x i m apl h a l a n xA. , l n th e d o r so p a lm avie
r w,th e r eis a n
ovo i dr a d i o l u c e ndte f ect in th e p r o xim apl a r t o f th e p h a r
an x t h a t s u r r o u n d sa sm a lie ro va lo p a city.Activep e r io s-
T e a n e w o o n e ' o r m a tcin ,sa lso e vio e n t.B, In th e la ie r -
om e d i a vl i e w t h e c o rticase l q u e str u mth , e d e fe ctin th e
un d e r l y i ncgo r t e x a
, n dth e a d ja ce npt e r io ste aplr o life r a tio n
ar e v r s i b l e .S e q u e s t ra tioonf b o n e m a y b e ca u se d b y
trauma-induced avascularnecrosisor bv bacterialcortical
os r e t l r s .
The P halanges281
Separation of a piece of P3 may represent a pathologic fracture or
sequestrum (Fig. 23-20).3?Clinically, a draining tracf at the sole or
coronary band may be found. Contrast sinography or images made
with a metallic stylet in the tract are usefullo confirm asiociation
with a bone lesion or to detect communication with the distal
interphalangealjoint or navicular bursa. To avoid iatroqenic intro_
duction of infection into the joint or bursa, an artirogram to
detectleakageout ofthe joint cavity should be consideredln those
horses with draining tracts at the coronary band. Extension of
infection-to these sl,novialcavitiesnecessiiates aggressive treat-
ment.3EIf a metallic foreign body is evident at phliicat examina-
tion, radiographsshould be made prior to ,.-ouul, to determine
of its penetration and ils relationship to the regional
l|."O"O,n
Septic arthritis
Infective agents are introduced into the joint by penetrating
wounds, by iatrogenic injections, or by hematogenousintroduction.
The latter occurs most commonly in foals. Iio*.u.r, neither the
proximal nor the distal interphalangealjoints are tlpically involved
in the septic polyarthritis syndrome of foals.3eAnvlaceration near
a joint that is associatedwith significant and persistent lameness
warrants concern for extension to the ioint and infection.
The joint pouches of the distal inrerphalangeal joint are quite
.
large. During the initial stageof infectior., tro .udiogiaphic changes
may be visible. Inflammation of the synoviu- arrd eff.,sion day
focal, enlargement or a bulge in the contour at the joint
:reaJe 1
level. If the distal interphalangeal joint is infected, a bulge at or
just proximal to the coronary band should be evident. {arely is
widening of the joint space detected, especiallyif the horse is still
bearing weight.aoLameness due to infeited joints is usually very
painful and the horse is reluctant to fully bear weight. This furthei
complicates critical assessmentof the width of the joint space.
Positive-contrast arthrography was used in horses with no bone
changesbut suspectedto liave joint infection.aoThis was successful
for identification of communication of the contrast medium from
the joint to the external wound. One of the earliest bone reaction
.
%.-.--rt,'
11,,,,;::,..ill
,.'lll'lllglll
282 SK EL E T O N -EOU IN E
A P P E NDIC U L AR
' " -* t r * . ' &- 'j g J . : - .' .
signs is fuzzinessat the joint capsuleinsertion or chondro-osseous
junction on the perimeter of the joint surfaces'As cartilagebegins
to deteriorate,thinning of the joint spaceis seen.As the infection
invades the deeper regions of the cartilage and reachesthe sub-
chondral bone, the subchondral bone margin becomes irregular
owing to iysis (see Figs. 23-l2E and F and 23-21). Lysis of the
subchondral bone causesthe joint to be unevenly widened'*oAt
this stage,periostealnew bone should be quite evident at the joint
margins. Septicarthritis alwayscarriesa guardedprognosis.
I Degenerative ioint disease
Degenerativejoint diseaseis a chronic disorder of slnovial joints
characterizedby progressivedeterioration of articular cartilage and
by reactivechangesin the joint margin and joint capsule.o'Among
the multiple causesof degenerativejoint diseaseare acute trauma,
infection, poor limb conformation, developmentalorthopedic dis-
ease,and chronic repetitive trauma associatedwith athletic activity
such as racing and other styles of competitive performance. These
causestypically produce what is thought of as secondarydegenera-
tive joint disease.Primary degenerativejoint disease,in compari-
son, is consideredan age-relateddiseaseof slow onset, resultingin
gradual degradationof normal joint structure and function. The
proximal and distal interphalangeal joints can be affected by any
of thesecauses.The generalchangesexpressedradiographicallyare
new bone formation (osteophytes)at the periarticular (chondro-
osseous)margin, enthesophytes at the sitesof supporting ligaments
and joint capsule,sclerosisand lucency in the subchondralbone,
and changesin the joint spacewidth (Figs.23-22 and 23-23). A
wide spectrum of combination and degree of the above changesis
seen (see Fig. 23-12). In the situation of secondarydegenerative
joint disease,radiographic changesunique enough to reveal the
primary insult may be present. However, in many horses, the
primary insult may not be evident.
The proximal interphalangealjoint is consideredto be a high-
load, low-motion joint, meaning that a large range of movement
does not occur during the stride motion of the 1imb. As a conse-
. i tut ttu t ltiu:tl
a
!\ . iiliUlr...ir!]ll,,.,rr
s il""iilillrl':iili$rlr'
- il
t9ut'titit9lu
l'i::Gllll.
iiill
Figure 23-2O. Serialdorsal65-degreeproximal-pa marodis-
tal proj ecti ons
of the pal marprocessesof the di stalphal anxo f
an acutel yl ameS -year-oiThoroughbred.
d A , In ti al exami natlon
show s mi nl malradographi cabnormal i ty. B , S i x days l ater,a
radiolucentdeIecI (arrow)is evident ln the medialpalmarpro-
cess w l th l oss of trabecuar bone detai l(comparew i th l ater al
pa mar process).C, N ne days later, more extensive ysis of
bonehasoccurred, w i th separati on
of a sequestered fragmen t.
The radi ograph c di agnosi si s septi costei trsw i th sequestru m
formatl on.
quence, a smaller region of the joint surface sustains a more
constant weight-bearingload for a longer period of time in the
athletic horse.n' This relationship is the basis of an explanation for
the characteristic features of progressiveproximal interphalangeal
degenerativejoint diseaseseen in athletic horses,especiallythose
active in Western-styleevents.a2The movements of athletic activity
are proposed to excessivelyconcentrate the load on the articular
cartilage and initiate fibrous thickening of the supporting soft
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
and resorption. The natural attempts to heal the cartilage lesions
are not successfuland gaps are left in the articular cartilage surface.
Osteogenicgranulation tissuefrom the exposedsubchondralbone
bridgesthesejoint gaps,initiating the processof ankylosis.
Radiographically, typical periarticular osteophytesand entheso-
phytes develop. Fibrous thickening of the joint capsule and collat-
eral ligaments,along with compressionremodeling of the articular
cartilage and subchondralbone, occurs but can be subtle radio-
graphically.Focal regions of subchondralbone resorption may be
large enough to be seenas lysis.The osteogenicgranulation tissue
in the subchondral sites of bone resorptionarbecomesvisible as
bone-to-bone contact. This is the start of bony ankylosisof the
joint (see Frg. 23-12F).
If these initial ankylosis sites are sufficiently stable, additional
ankylosisprogressesto complete the union of the bone surfaces.
However, if activity is continued, the initial ankylosis sites can
break down and generatemore periarticular new bone (see Fig.
23-23). During the ankylosis process,lamenessis likely to persist.
In these horses, the natural ankylosis must be replaced by surgical
arthrodesisso that the lamenesscan be resolved.
In the standard imagesof the proximal interphalangealjoint, the
new bone changesare readily seen in all views. The subchondral
bone sclerosisand resorption changesare most easilyseenon the
dorsopalmar or oblique views. Adequate x-ray beam penetration
and careful scrutiny of the subchondralbone margin are necessary
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 .

increased opacity of irregularly deposited new bone formation

adjacent to unaffected bone can simulate decreasedbone opacity,
which may then be misinterpreted as bone lysis. Correlating the
location of new bone in all views helps to avoid this misinterpreta-
tron.
Osteoarthritis, due to causes other than infection or articular
fracture, is much less frequently reported with specific referenceto
the distal interphalangealjoint. It is also not as obvious radiograph-
ically. When present, the radiographic signs of osteoarthritis are
small periarticular osteophytes on the dorsal edges of P2 and P3
(see Fig. 23-17), enthesophyteson the eminencesfor the collateral
ligaments on P2, and narrowing of the distal interphalangealjoint.
If asymmetrical narrowing of the joint is noted on the dorsopalmar
view (see Fig. 23-l2B), this may be due to true asymmetrical
cartilage degeneration,asymmetricai weight bearing, or unbalanced
compressive forces due to unbaianced trimming or wear of the
hoof.

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
io be at risk for developing contralateral limb laminitis.n'
Although there continue to be differences of opinion as to the
terminology and categorization of this complex, several clinical
phasesor stagesof laminitis are recognized: developmental, acute,
and chronic.'u Developmental laminitis is defined as the period
between the initial insult to the first expressionof lameness.It may
be as short as 24 hours or as long as 60 hours.a6This is very likely
an imperceptible stageto the owner, unless accessto excessivegrain
is known to have occurred or a systemicdiseaseor other condition
is present that warrants concern for initiation of laminitis. This
perlod is a prevention phase for mechanical failure of the foot
complex.'u Acute laminitis representsthe phase from the first ex-
oression of lameness through 72 hours without evidence of me-
ihanical collapse, or it ends-at any time that signs of mechanical
collapseoccur.a6Radiographs may be indicated in either the devel-
opmental or the acute phase to serve as a baseline for future
comparison. Horses may fully recover from either developmental
or acute laminitis. If, however, radiographic or clinical signs of
distal phalanx displacement are seen,the phase of chronic laminitis
has been entered.a6
Radiographic evaluation of laminitis
Radiographic evaluation of any horse with a clinical impression of
pain and lamenessdue to laminitis is justified. The goals of radiog-
raphy are to detect changesindicative of mechanical failure and to
observe changes that contribute to the formulation of prognosis
and therapy. All four feet should probably be evaluated initially.
Although lameness may be expressedin only one leg, structural
changesmay be radiographically present in severalfeet. Front feet
are most commonly affected. Optimal lateromedial, dorsopalmar,
and dorsal 65-degree proximal-dorsodistal oblique views are rec-
ommended. Placement of radiopaque markers on the hoof wail
has been advocatedto aid in identifying soft-tissue landmarks."-e
One marker is placed on the midsagittal plane at the junction of
Figure 23-24. A, Severepalmardeviation-rotation of the distal
Ga sis se e nbetw eenthe
fr o m ch r o n icla m in itis.
p h a l a n xr e s u ltin g
h o o f w a l l a n d th e so ft tissu e so f th e co r iu m .In d istl nctdorsal
surface(solidarrow./and dorsalangulation("ski-tip"appearance)
o f t h e t o e o f th e d ista l p h a la n x( o p e n a r r o w) a r e addi ti onal
c h a n g e ss e e n in ch r o n icla m ln itis.B, Pa th o lo g ic typ e V l fracture
o f t h e d i s t a lph a la n xse co n d a rto
y la m in itis.A th in b o nefragment
is separatedfrom the solarmargin(white arrow).Punctateradlo-
l u c e n t d e f e cts ( b la cka r r o ws)a r e e n la r g e dva scu l archannel s
viewed end-on. C Larger fracture of the toe with concurrent
palmardevlation-rotation. The largeaccumulationof gas between
t h e h o o f w a ll a n d th e la m in a rco r iu m is m o st likel ydue to a
c o n c u r r e nsut b so laar b sce ssa n d se p tlco ste itis.
the hoof wall and the coronarv band. The second, a linear marker
preferably of known length, ii placed on the midsagittal plane of
the dorsal hoof wall (Fig. n-2aC). This should be of sufficient
Iength to extend approximately half to two-thirds the length of the
dorsal hoof wali. The third is placed at the point of the frog of the
sole. Some place a fourth marker on the white line junction of the
hoof wall and heel bulb (angle of the wall). These markers not
only assist in initial radiographic assessmentbut also assist in
measurement or identification of landmarks needed for planning
corrective shoeing.
The radiographic signs of distal phalanx displacement are defin-
itive for the presenceof chronic laminitis. The sign seen is either
palmar deviation (rotation) of P3 from the hoof wall, distal (verti-
cal or sinking) displacement of P3, or a combination of both. A
spectrum of severity is found. In the normal foot, the dorsal cortex
of P3 should be parallel to the dorsal margin of the hoof wall in
the lateromedial view. Divergence of these surfaces,with the toe
region of P3 deviating or rotating in a palmar direction, is an
indication of mechanical separation of the dermal and epidermal
laminae (see Fig. 23-2M). This is the easiestof the P3 displace-
ments to detect radiographically. When a straight edge is used to
mark the comparative lines of the hoof wall and dorsal cortex (Fig.
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
region and convergeproximally. The angle at the point of conver-
gence can be measured and is referred to as the degree of rotation
(seeFig. 23-25C).
Vertical displacement of P3 can be more difficult to detect and
is often overlooked.to In the normal foot, the proximal edge of
the extensor processof P3 is positioned roughly at the same plane
or just proximal to the junction of the hoof wall and coronary
band.aa'srThe vertical distance between the proximal limit of the
dorsal hoof wall and the proximal limit of the extensor process of
P3 has been measured to generate a "founder" distance (see Fig.
23-2581.nt\A/hen corrected for magnification, this distance in 25
 The Phalanges 285

Figure 23-25- Radlographic measurementsof the normaland laminiticfoot. A and B,

Normalfoot. Line a is parallelto the hoof wall. Line b is parallelto the dorsalcortexof the c
distal phalanx. Linec is parallel to the weight-bearing surfaceof the hoof wall. Angle ac is
the hoof axis. Angle bc is the foot axis. 1p is the thicknessof the dorsal soft tissues
measured5 mm distalto the junctionof the extensorprocesswith the dorsalcortex. 1d
is the thicknessof the dorsalsoft tissues measured6 mm proximalto the most distal
point of the dorsalcortex. Line 2 is the length of the palmarcortex measuredfrom the
solar marginat the distaltoe to the palmararticularedge between the distalphalanxand
the distal sesamoid bone. Distance3 is the vertical distance or "founder" distance
measuredbetween coronaryband and proximaledge of the extensorprocess.C, Foot
with chronic laminitisexhibitingP3 displacementas rotationonly. Lines a and b are no
longer paralleland convergeproximallyforming angle ab or the rotationangle. Distance
1' d i s g r e a t e rt h a n d i sta n ce1 ' p . D, F o o twith ch r o n icla m in itisexhi bi ti ngP 3 di spl acement
as v e r t i c a ld i s p l a c e m e n(tsin kin go) n ly. F o u n d e rd ista n ce3 ' is i ncreased.D i stance1"p
equals1"d. but both are greaterthan normal.The percentagethat 1"d is of line 2 will be
greaterthan normal.(Seetext for normaland abnormalvalues.)(FromLindfordRL,O'Brien
TR, TroutDR: Oualitativeand morphometricradiographic findingsin the distalphalanxand
digitalsoft tissues of sound Thoroughbredracehorses.Am J Vet Res 54:38, 1993; and
CrippsPJ. EustaceRA: Radiological measurementsfrom the feet of normalhorseswith
relevanceto laminitis.EquineVet J 31:427,1999.) D
286 S KE L ET ON -EOU IN E
A P P E NDI CU L AR
normal horses was an averageof 4 mm (range, -2 to 11 mm) in
the front feet and an averageof 4.6 mm (range, -2 to 9 mm) in
the hind feet.a8
An increase in the thickness of the dorsal soft tissues has been
suggestedto be a very early sign of laminar inflammation or edema
and thus a sign of acute laminitis. The thickness of the dorsal soft
tissues has been measured on radiographs of clinically normal
horses.to'45' 4s'4e A statistical difference was found in thickness
among normal ponies, Hanoverians, and Thoroughbreds.nt The
averagethickness of the front feet for all horses, when corrected
for magnification,was 16.3 mm (range, 11.1to 20.2 mm).a'When
only Thoroughbreds were compared between the Cripps and Lin-
ford studies,to'a8 the averagethicknesswas 16.3mm (range, 13.9to
19.7 mm) comparedwith 14.6 mm, respectively(both valuescor-
rected for magnification). For other specified breeds, from Cripps'
study, the measurements(corrected for magnification) were found
for the front feet rangesof ponies (11.1to 16.1mm) and Hanoveri-
ans (17 to 19.1 mm); and for the hind feet rangesof ponies (11.7
to 16.1 mm), Hanoverians(15.9 to 20.4 mm), and Thoroughbreds
(14.3 to 17.9 mm).asA marker of known length must be in the
image to correct for magnification. If this is not available, an
alternative is to calculate the dorsal soft-tissue thickness as a per-
centage of the palmar cortex length. In 41 sound Thoroughbreds,
the average was 24.2o/o,and a measurement greater Ihan 28.1o/o
shouid be considered abnormal for the Thoroughbred (see Fig.
23-258 and D).'0 When not corrected for magnification, a dorsal
soft-tissue thickness greater than 20 mm has been suggestedto be
abnormal for any breed.t'
Other radiographic changesthat can be seen with chronic and
progressivelaminitis include a sole that is very thin. The change in
the position of the toe of P3 may causea convex bulge in the sole's
contour or the toe may penetrate through the sole. Radiolucency
at the laminar junction can be seen as a single linear lucency in
the lateral view (see Fig. 23-2M) and as a series of parallel linear
lucencies in the dorsal 65-degree proximal palmarodistal oblique
view. This linear radioiucency is attributed to air dissectingbetween
the hoof wall and the laminar corium when necrosis has eroded
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
in the dorsal 65-degree proximal palmarodistal obiique view (see
Fig. 23-248). These lucencies represent an increased number of
and wider vascular channels extending from the solar canal to the
dorsal cortex. This is typically seen in combination with new bone
along the dorsal cortex. The new bone also creates a prominent
domed shape to the dorsal surface of the distal phalanx. The toe
of P3 frequently develops a "lipping" shape due to either new
bone, resorption of the palmar cortex, or an angular orientation
of a solar margin fracture (type VI) (see Fig. 23-24A and B).
Osteitis of variable severity usually develops. Additionally, disuse
of the limbs can further decreasethe bone's opacity. Infectious
osteitis can occur in the most severelyaffected horses. A break in
the pastern angle (rotation of P3 about the distal interphalangeal
joint) can occur if contraction of the deep digital flexor tendon
occurs, or if the more rapid growth of the hoof wall at the heel is
improperly managed.
Because of the severe morbidity and protracted treatment re-
quired for chronic laminitis, indicators of prognosis for successor
failure of treatment are desired. Various radiographic measure-
ments have been assessedretrospectively in an effort to define
reliable predictors of outcome for horses with chronic lami-
Figure 23-25 illustrates several of these measurements.
nitis.le'53'51
Even though none has been completely reliable when used as the
only indicator, trends have been identified. In general, the more
deviant from normal, the more guarded to worse the prognosis. In
a series of 91 horses, the degree of P3 rotation was inverseiy
correlated with return to athletic performance. Horses with less
than 5.5 degreesof deviation had a favorable prognosis for return
to athletic work, horses with 6.8 to 11.5 degreeshad a guarded
prognosis, and horses with more than 11.5 degreesof deviation
were not useful as performance animals, but some could be sal-
vaged for breeding.s3In another study, neither the degree of distal
phalanx rotation nor distal displacement correlated with outcome,
and lameness severity was a more accurate predictor.saIn a very
recent study, of those horseswith severeclinical featuresof chronic
laminitis, 54% with a rotation angle greater than 20 degreesand
B8o/owith a rotation angle less than 2 degreeswere successfully
treated and returned to rideable soundness." As a predictor of
outcome to riding soundness,founder distance was useful when it
was either in the low range of normal or well beyond the upper
limit. In horses with severe chronic laminitis, no animal with a
founder distance less than 7.9 mm failed to respond to treatment,
and only one horse with a founder distancegreaterthan 15.2 mm
was a success.ae However, that author found some horses with
palpation findings along the coronary band typical of a sinking P3
to have founder distanceswithin the normal range. Using Linford's
measurement of dorsal soft-tissue thickness (measuredat the distal
point) calculated as a percentage of the palmar cortex length, a
measurementof greaterlhan 2B.Io/oshould be consideredabnormal
for the fore foot of Thorouehbreds.l0Dorsal wall thickness was not
found to be an isolated piedictor of outcome with treatment.ae
Even so, Pelso found increased dorsal soft-tissue thickness to be a
risk factor for development of clinical laminitis in the contralateral
limb of horses with unilateral limb lameness.4sIn that series of
horses, increased dorsal wa1l thickness and sinking were more
common than palmar deviation of P3. Some cautions regarding the
use of radiographic measurementsdeservemention. Measurements
probably are most valuable when used for serial assessmentof an
individual horse. Very strict attention to detail must be maintained
in the production of images. Positioning of both the horse's foot
and the x-ray beam is critical. An oblique projection angle can
significantiy alter measurement. Likewise, placement of any mark-
ers should be standardized.Failure to adhere to strict standardiza-
tion renders comparative measurementsunreliable.
I Flexural deformity of the
I interphalangealioints
Distal interphalangeal ioint
This is the most common of the flexural deformities of the phalan-
ges.The clinical appearanceof this is an almost vertical orientation
of the hoof wall to the ground (Fig. 23-26). Flexural deformity may
be either congenital or acquired. Genetic influences and teratogenic
insults during embryonic developmental are factors that may lead
to congenital deformities.l ssThe acquired form is most common
in rapidly growing foals and has been related to pain that initiates
a persisting flexion withdrawal response,lack of exercise,or poor
nutritional management in the growing foal. Both overfeeding and
unbalanced diets have been cited as potentiating factors.56The
exact manner in which these various influences interact to produce
flexural deformities is unknown, but several theories suggest a
difference in the rate of bone growth versus tendon and ligament
lengthening.sqs7A11theories imply a faster rate of lengthening of
metacarpal III or metatarsal III than for the deep digital flexor
tendon-check ligament unit. Increasing tension on this tendon-
ligament unit leads to flexion of the distal interphalangeal joint,
with the foal assuming a "toe dancer" stance.Changesseen in the
distal phalanx of thesefoals range from none to varying irregularity
of the solar margin centered at the toe. The irregularity is due to
widened vascular channels and bone resorption at the solar mar-
gin.58 If the deformity is corrected early, the bone changes can
resolveto a normal appearance.
 The P halanges287

a systemic disease,or after prolonged periods of external support

(splinting or casting) of the leg.. Acquired hyperextension is also
causedby rupture of the deep digital flexor tendon or avulsion of
its insertion (Fig. 23-28). This lesion occurswith traumatic lacera-
tion of the tendon or extension of infection from a deeo sole
abscessto the palmar surface of the distal phalarx.

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
19llll.l"'".ii.,i1:
i,rl9ii:)),,.-.r1:
rSrr,,.,,,!liilil"'l
ria:lrli.,l
rr"rrl9ll"
Figure 23-28. Luxationof the distalinterphalangeal joint secondary to
andpathologic
osteomyelitis of theflexorsurface
fracture of thedistaiphalanx
of thedistalphalanx of thedeepdigital
is dueto avulsion
Dorsaldisplacement
flexortendoninsertionand the subsequent unreciprocatedtractionof the
commondigitalextensor tendon. Thedistalsesamoidean imparligament is
alsoruptured, proximal
allowing displacement of thenavicularbone
clinically sound older horses presented for pre-purchase evalua-
tion.63 The subchondral cystlike defects in the distal part of the
proximal phalanx frequently lead to extensive degenerativejoint
diseasein the proximal interphalangeal joint (see Fig. 23-298). ln
such instances,surgical arthrodesis may be needed to allow return
to useful function.t'' u6'6tIn one seriesof 13 horsesin which solitary
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
could not be identified radiographically 1.5 to 2.5 years after the
initial diagnosis.
I Pedal osteitis
Diffuse roughening of the solar border of the distal phalanx, creat-
ing a ragged, lacy appearancewhen viewed in the lateromedial or
dorsal 65-degree proximal palmarodistal oblique projection' may
be an indication of pedal osteitis.ePedal osteitis is the responseof
the distal phalanx to inflammation and is manifestedby demineral-
izatron, eiiher focal or more diffuse. The changeis most commonly
seen secondary to chronic bruising, sole abscesswithout extension
of infection in the bone, flexural deformities, and other condi-
tions.6eOnce the primary insult and pedal osteitis become inactive,
there is frequently little change in the appearanceofthe roughened
contour of the solar margin. Also, because there is considerable
variation in the appearanceof the solar surfaceof the normal distal
phalanx, a mild degreeof irregularity may be misleading. A positive
response to hoof testers, an increased number and diameter of
vascular channels seen concomitantly with demineralization of the
bone, and thinning of the sole of the foot increasethe probability
of pedal osteitis as a current cause of lameness.Thus clinical signs
must be consideredin the determination of whether a radiographi-
cally irregular margin of the distal phalanx is an indicator of
current or previous pathology.
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
indicates the junction between a separate,peripheral ossification
center and that part of the cartilage that is ossifring from the
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
at the base or attachment of the cartilage to the palmar process
can extend to involve the palmar processand the distal interphalan-
geal joint.
Infection (quittor)
Penetrating wounds or lacerations in the coronary band region can
introduce infection into the collateral cartilaees.Necrosis associated
with infection of this cartilage is called quittor. In acute infections,
radiography should be considered to rule out a metallic foreign
body or deeper lesion in the adjacent bones. In chronic infections,
a draining tract is tlpical. Extension to the distal interphalangeal
joint is uncommon unless it occurs iatrogenically during aggressive
establishment of drainage or dEbridement of the necrotic cartilage.
I Hoof balance
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
joint diseaseofthe interphalangealjoints. Lateromedial and dorso-
palmar radiographic views of the foot can be used in conjunction
with direct measurementson the foot to assessfoot balance.e'73 7s
When radiographic views are used in this manner, particular atten-
tion must be paid to positioning of the foot, center of the x-iay
beam, and degree of weight bearing on the limb being assessed.
The measurementsused to assessfoot balance radiographically are
shown in Figve 23-32. In the lateromedial view, the dorsal hoof
wall should be parallel to the wall at the heel. The pastern axis, as
seen in the lateromedial view, is a line that divides the middle
phalanx into equal dorsal and palmar halves. Ideally, this line
similarly bisects the proximal phalanx and is parallel to the dorsal
cortex of the distal phalanx. When this line is carried through to
intercept with a line on the bearing surface of the hoof wall, it
should create an angle of 45 to 55 degrees(front foot) or 50 to 55
degrees (hind foot) with the bony solar margin.3' 73 Significant
differenceswere induced in the anglesof the interphalangealjoints
when the hoof angle was altered.T3The greatestdifference in angle
occurred in the distal interphalangeal joint. Clinically, such a
change in the angle of the distal interphalangeal joint is suggested
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

Figure 23-29. Dorsopalmarviews of solitary,radiolucentsubchondral

o f th e proxmal phal anx.
c y s t - l i keb o n ed e fe cts{ o ste o ch o n d r o sis) A , E l i pti c
d e f e c twith n a r r o wn e ck- like co n n e cto n to a r tic ul ar
carti l age4oispace
nt and
s u r r o un d inzo g n e o f scle r o sis.Oste o a r th r o sis is not evi denti n ths 1-year-
o l d T h o r o u g h b r e dB,. Sp h e r icad e fe ctsu r r o u nded by scl eroti csubchondral
b o n e .Co lla p se o f co n tig u o ujo
s in tsp a cea n d p e rl arti cul osteophyte
ar forma-
tion indicatethe presenceof osteoarthrosisin a 6-year-oldOuarter horse
t h a t h ad b e e n la m efo r ' l m o n th .

The angle of intercept of a line parallel to the solar margin of the

distal phalanx and the line of the weight-bearing surface of the
hoof wall should be 5 to 10 degrees.'The length of the toe region
comparedwith the heel region of the bearing surfaceof the hoof
wall is judged by comparisonwith the distal interphalangealjoint.
A line from the center of the best fit circle of curvature of the joint
space, when drawn perpendicular to the weight-bearing surface,
should be at the middle of the weight-bearing surface.n, 'u The
lateral and medial portions of the hoof wall should be of equal
length. An elaborate set of measurementshas been made on the
dorsopalmar view to assessthe effects of uneven mediolateral hoof
wall trimming.T4'7sThis method was used to assessthe effectsof
using the corrective full rolling shoe in horses lame owing to
interphalangeal degenerativejoint disease.TT
I Miscellaneousdiseases
I affecting the phalanges
Keratoma is an abnormal mass of squamous epithelial cells with
abundant keratin and granulation tissue. These ievelop within the
hoof wall or in the sole. They are consideredto be causedby
traumatic or infectious insult to the hoof.TsHorses in that report
had been lame for reiativelylong periods of time owing to prior
hoof injuries. Developmentof keratoma is rare.
Visible deformity of the hoof wall or sole is clinically evident.
The mass effect can cause localized osteolysisof an adjacent area
of P3. The lytic region typically involves the surface of p3. An
oblique projection angle may be neededto demonstratethis fea-
ture. The margins of the lytic area are smooth, and the shape is

Figure 23-31. Asymmetric ossificationof the colateral cartiage of the

Figure 23-3O, Ossificatonof the collateralcartilageof the dista phalanx. di sta phal anxmay l ndi cateabnormalstresson the affecteds de of the fooi
U n i f o r mo s s l f i c a t l oins se e n in b o th th e a te r a a n d th e m e d ialcol l ateral
carti - and w arrantscl oseexami nati on of the hee and navi cui ar
b one for adc l tona
la g e .S u c h a d v a n c e dch a n g e su su a llyd o n o t ca u se a m e n e ssi f the foot i s abnormal j ti es.
In thi s horse,the radi ol ucent
deIecI(arrow i)s a c artl age ren--
br o a da t t h e h e e l . nanti l etw eentw o separatecentersof ossi fi catron,
not a fra c rure.
2 9O A P P E NDI C U L ASRKE L ET ON -EOU IN E

Figure 23-32. Radtographic measurements for foot balance. A, Assessment

fromlateromedial viewof normal foot.a, Lineparalle to dorsal hoofwall;b, Line
paralleto dorsalcortexof distalphalanx; c, Linethatbisects themiddlephalanx
lntoequaldorsal andpalmar halves; d, Linedrawnparallel to the bulbsof the
heel;e, Linedrawnparallel to the solarsurface of distalphalanx; f, Linedrawn
paralelto the bearrng surface of the hoofwall;g, Linefromcenterof bestfit
circlefor the d stal interphalangeal jointdrawnperpendicular to the bearing
surface of the hoofwall.Linea shouldbe parallel to linesb, c, andd. Lineg
shouldintersect at the midpoint of the bearing surface of the hoofwall.Angle
af,45*55degrees in a frontfoot;50-55degrees in a hindfoot;Angleef, 5-10
degrees. B, Assessment from dorsopamar view of the normalfoot. 1, Line
bisectingthe phalanges. 2 & 3, Linesfromrespective ateralandmedialsolar
margins of distalphalanx to bearing surface of thehoofwall.Theselinesshould
be parallel
to line1. Distance :
2 3.

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
The majority of animals had intrathoracic diseaseassociatedwith l. Nyrop KA, Coffman jR, DeBowes RM, et al: The role of diagnostic nerve blocks
the limb lesions. The bilateral symmetry, multilimb involvement, in the equine lameness examination. Comp Contin Educ Vet Pract 5:5669, 1983.
and character of the periosteal new bone are very characteristic of 2. Morgan JR Neves J, Baker T: Equine Radiography. Ames, Iowa State University
this disease. Pr es s ,1991.

' 3. StashakTS: Adams' Lamenessin Horses. Philadelphia, Lea & Febiger, 1987.
4. Schebitz H, wilkens H: Atlas of Radiographic Anatomy of the Horse. Philadelphia,
WB Saunders,1978.
5. Smallwood JE, Holliday SD: Xeroradiographic anatomy of the equine digit and
metacarpophalangealregion. Vet Radiol 28:166, 1987.
6. Kneller SK, Losonsky lM: Variable locations of nutrient foramina of the proximal
phalanx in the forelimbs of Thoroughbreds. J Am Vet Med Assoc 197:736, 1990.
7. Losonsky JM, Kneller SK: Variable location of nutrient foramina of the proximal
phalanx in the forelimbs of Standardbreds.J Am Vet Med Assoc 193:671, 1988.
8. Rendano Vl Grant B: The equine third phalanx: Its radiographic appearance. J
Am Vet Radiol Soc 19;125,1978.
9. Butler FA, Colles CM, Dyson Sf, et al: Clinical Radiology of the Horse. London,
Blackwell Scientific Publications, 1993.
10. Linford RL, O'Brien TR, Trout DR: Qualitative and morphometric radiographic
findings in the distal phalanx and digital soft tissues of sound Thoroughbred race-
h o rse s.A m J V e t Re s54:38,1993.
11. Smallwood lE, Albright SM, Metcalf MR, et al: A xeroradographic study of the
developing equine foredigit and metacarpophalangealregion from birth to six months
of age.Vet Radiol 30:98, 1989.
12. Kaneps AJ, Stover SM, O'Brien TR: Radiographic characteristics ofthe forelimb
distal phalau and microscopic morphology of the lateral palmar processin foals 3-32
weeksold. Vet Radiol Ultrasound 36:179,1995.
13. Weaver JCB, 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.
14. Mcllwraith CW, Goodman NL: Conditions of the interphalangeal joints. Vet Clin
North Am Equine Pract 5:161, 1989.
15. Kawcak CE, Mcllwraith CW: Proximodorsal proximal phalanx osteochondral chip
fragmentationin 336 horses.Equine Vet J 26:392,1994.
16. Markel MD, Richardson DW: Noncomminuted fractures of the proximal phalanx
in 69 horses.J Am Vet Med Assoc 186:573,1985.
17. Ellis DR, Simpson Dl, Greenwood RES, et al; Observations and management of
fractures of the proximal phalanx in young Thoroughbreds. Equine Vet I 19:43, 1987.
18. Fackleman GE, Peutz IR Norris lC, et al: The development of an equine fracture
documentation system. Vet Comp Orthop Trauma 6:47, 1993.
19. Holcombe SJ, Schnieder 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.
20. Markel MD, Martin BB, Richardson DW: Dorsal frontal fractures of the proxinal
phalanx in the horse.Vet Surg 14:36,1985.
21. Markel MD, Richardson DW, Nunamaker DM: Comminuted proximal phalanx
liactures in 30 horses, surgical vs. nonsurgical treatments. Vet Surg 14;135, 1985.
22. Tetens L Ross MW, Lloyd JW: Comparison of racing performance before and after
treatment of incomplete, midsagittal fractures of the proximal phalau in Standard-
breds:49 cases(1986-1992).J Am Vet Med Assoc210:82,1997.
23. Goodman NL, Baker BK: Lamenessdiagnosis and treatment in the Quarterhorse
racehorse.Vet CIin North Am Equine Pract 6:85, 1990.
24. Dechant JE, MacDonald DG, Crawford WH: Repair of complete dorsal fracture
of the proximal phalanx in two horses. Vet Surg 27:445, 1998.
25. Rose PL, Seeherman H, O'Callaghan MO: Computed tomographic evaluation
of comminuted middle phalangeal fractures in the horse. Vet Radiol Ultrasound
38:424,1997.
26. Colahan PT, Wheat JD, Meagher DM: Treatment of middle phalangeal fractures
in the horse.I Am Vet Med Assoc 178:1182,1981.
27. Mafiin GS, Mcllwraith CW, Turner AS, et al: Long-term results and cornplications
ofproximal interphalangeal arthrodesis in horses. I Am Vet Med Assoc 184:1136,1984.
28. Doran RE, White NA, Allen D: Use of a bone plate for treatment of middle
phalangeal fractures in horses; Seven cases (1979 1984). J Am Vet Med Assoc
1 9 1 :5 7 5 ,1 9 8 7 .
29. Crabill MR, Watkins lR Schneider RK, et al: Double-plate fixation of comminuted
fracturesof the secondphalanx in horses:l0 cases(1985-1993).J Am Vet Med Assoc
207:1458.1995.
30. Gabel AA, Bukowiecki CF: Fractures of the phalanges.Vet Clin North Am Large
Anim Pract 5:233,1983.
31. Honnas CH, O'Brien TR, Linford RL: Distal phalanx fractures in horses: A survey
of 274 horses with radiographic assessment of healing in 36 horses. Vet Radiol
29;98, 1989.
32. Scott EQ, McDole M, Shires MH, et al: A review of third phalanx fractures in the
horse: 65 cases.J Am Vet Med Assoc 174:L337, 1979.
The Phalanges291
33. Scott EQ, McDole M, Shires MH, et al: Fractures of the third phalanx (P3) in the
horse at Michigan State University, 1964-1979. In Proceedings of the 25th Annual
Convention of the American Association of Equine Practitioners, 1979, Miami, p 439.
34. O'Sullivan CB, Dart AJ, Malikides N, et al: Nonsurgical management of tlpe II
ftacturesofthe distal phalanx in 48 Standardbredhorses.Aust yetl 77i50I,1999.
35. Kaneps AJ, O'Brien TR, Redden RF, et al: Characterization of osseous bodies of
the distal phalanx of foals. Equine Vet I 25:285, 1993.
36. Kaneps AJ, O'Brien TR, Willits NH, et al: Effect of hoof rrimming on the
occurrence of distal phalangeal palmar process fractures in foals. Equine Vet J Suppl
26:36, 1998.
37. Baird AN, Seahorn TL, Morris EL: Equine distal phalangeal sequestration. Vet
R adi ol 31:210,1990.
38. Cauvin ERJ, Munroe GA: Septic osteitis of the distal phalanx: Findings and
surgicaltreatment in 18 horses.Equine Vet J 30:512,1998.
39. Steel CM, Hunt AR, Adams PL, et al: Factors associated with prognosis for
survival and athletic use in foals with septic arthritis: 93 cases(1987-1994). J Am Vet
Med Assoc 215:973,1999.
40. Honnas CM, Vacek JR, Schumacher J: Diagnostic and therapeutic protocols for
septic arthritis of the distal interphalangeal joint. Vet Med Dec:1215, 1992.
41. Pool RR, Meagher DM: Pathologic findings and pathogenesisofracetrack injuries.
Vet Clin North Am Equine Pract 6:1, 1990.
42. Pool RR: Pathologic manifestations of joint disease in the athletic horse. In
Mcllwaith CW Trotter GW (eds): Joint Disease in the Horse. Philadelphia, WB
Saunders,1996.
43. Kainer RA: Clinical anatomy of the equine foot. Vet Clin North Am Equine Pract
5:1,1989.
44. Goetz TE: Anatomic, hoof aird shoeins considerations for the treatment of lami-
ni ti s i n hor s es .I Am Ver M ed As 5oc190:1j 23,1987.
45. Peloso ]G, Cohen ND, Walker MA, et al: Case-control study of risk factors for the
development of laminitis in the contralateral limb of Equidae with unilateral lameness.
J Am Vet Med Assoc 209:1746, 1996.
46. Hood DM: Laminitis in the horse. Vet Clin North Am Equine Pract 15:287, 1999.
47. Curtis S, Ferguson DW Luikart R, et al: Tiimming and shoeing the chronically
affected horse. Vet Clin North Am Equine Pract 15:463, 1999.
48. Cripps PJ, EustaceRA: Radiological measurements liom the feet of normal horses
with relevanceto laminitis. Equine Vet J 3\:427, 1999.
49. Cripps Pl, Eustace RA: Factors involved in the prognosis of equine laminitis in
the UK. Equine Vet J 31:433,1999.
50. Baxter GM: Acute laminitis. Vet Clin Nofih Am Equine Pract 10:627,1994.
51. Herthel D, Hood DM: Clinical presentation, diagnosis, and prognosis of chronic
laninitis. Vet Clin North Am Equine Ptact \51375.1999.
52. O'Brien TR, Baker TW: Distal extremity examination: How to pedorm the radio-
graphic examination and interpret the radiographs. In Proceedingsof the 32nd Annual
Convention of the American Association of Equine Practitioners, 1986, Nashville,
p 553.
53. Stick JA, Hann HW, Scott EA, et al: Pedal bone rotation as a prognostic sign in
laminitis of horses.J Am Vet Med Assoc 180:251,1982.
54. Hunt RJ: A retrospective evaluation of laminitis in horses. Equine Vet J 25:61,
1993.
55. Mcllwaith CW, JamesLR: Limb deformities in foals associatedwith ineestion of
locoweedby mares.J Am Vet Med Assoc 181:255,1982.
56. Owen JM: Abnormal flexion of the corono-pedal ioint or "contracted tendons" in
unw eanedfoal '. Lqui ne Vet I 7:40. 1975.
57, Fackelman GE: Equine flexural deformities of developmental origin. In Proceed-
ings of the 26th Annual Convention of the American Association of Equine Prac-
titioners, 1980,Anaheim, CA, p 97.
58. Arnbjerg ]; Changes in the distal phalanx in foals with deep digital flexor tendon
contraction. Vet Radiol 29:65, 1988.
59. Grant BD: The pastern joint. In Mansmann RA, McAllister EG (eds): Equine
Medicine and Surgery, 3rd ed. Santa Barbara, CA, American Veterinary Publications,
t982.
60. Shiroma lT, Engel HN, Wagner PC, et al: Dorsal subluxation of the proximal
interphalangeal .joint in the pelvic limb of three horses. J Am Vet Med Assoc 195:777,
1989.
61. Wagner PC, Watrous Bl: Equine Pediatric Orthopedics: A Practitioner Monograph.
Santa Barbara, CA, Veterinary Practice Publishing, 1991.
62, Wagner PC, von Matthiessen P: Treating congenital limb deformities in the foal.
Vet Med 1993,p 989.
292 A P P E NDI CU L AR
S KE L ET ON -EOU IN E
63. Do.ivling BA, Dart AJ, Hodgson DR: Subchondral cystic lesions involving the
second phalanx in trvo horses. Aust Vet J 76:328,1.998.
64. Hurtig MB, Pool RR: Pathogenesisof equine osteochondrosis. In Mcllwraith CW,
Trotter GW (eds): Joint Diseasein the Horse. Philadelphia, WB Saunders, 1996.
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
Assoc 180:1312,1982.
66. Trotter GW Mcllwraith CW: Osteochondritis dissecans and subchondral cystic
lesions and their relationship to osteochondrosis in the horse. Equine Vet Sci 5:157,
1 9 81 .
67. Trotter GW, Mcllwaith CW: Osteochondrosis in horses: Pathogenesisand clinical
slndromes. In Proceedings of the 27th Arnual Convention of the American Associa-
tion of Equine Practitioners, 1981, New Orleans, p 141.
68. Pettersson H, Reiland S; Periarticular subchondral bone cysts in horses. CIin
Orthop 62:95, 1969.
69. ReevesMJ, Yovich fV, Turner AS: Miscellaneous conditions ofthe equine foot. Vet
Clin North Am Equine Pract 5:221, 1989.
70. Reid CF: Radiography and the purchase examination in the horse. Vet Clin North
Am Large Anim Pract 2:151, 1980.
71. Ruohoniemi M, Tulamo R-M, Hackzelt M: Radiographic evaluation of ossification
of the collateral cartilages of the third phalanx in Finnhorses. Equine Vet i 25:453,
1993.
72. Moyer W, Arderson JP; Sheared heels: Diagnosis and treatment. J Am Vet Med
Assoc 166:53,1975.
73. Bushe T, Turner TA, Poulos P, et al: The effect of hoof angle on coffrn, pastern,
and fetlock joint angles. Proc Am Assoc Equine Pract 33:729, 1987.
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
45:319, 1998.
75. Caudron I, Grulke S, Farnir F, et al: Radiographic assessmentof equine interpha-
langeal joints asymmetry: Articular impact of asymmetric bearings (part n). t Vet
Med 45:319,1998.
76. Colles CM: Interpreting radiographs 1: The foot. Equine Vet I 15:297, 1983.
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.
78. Lloyd KCK, Peterson PR, Wheat JD, et al: Keratomas in horses: Seven cases
(1975-1986).I Am Vet Med Assoc 193:967,1988.
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.
80. Messer NT, Powers BE: Hlpertrophic osteopathy associatedwith pulmonary in
farction in a horse. Comp Contin Educ Vet Pract 5:5636, 1983.
81. SweeneyCR, Stebbins KE, Schelling CG, et al: Hlpertrophic osteopathy in a pony
with a pituitary adenona. I Am Vet Med Assoc 195:103, 1989.
82. Mair TS, Dyson Sj, Frasser lA, et al: Hypertrophic osteopathy (Marie's disease)in
Equidae: A review of twenty-four cases.Equine yet J 28:256, 1996.
83. Samii VR O'Brien TR, Stannard AA: Radiographic features of mastocltosis in the
equine limb. Equine Vet J 29:63, 1997.
ffi Ouestions
l. A 7-year-old Quarter horse mare, retired from racing, Pre-
sented with a history of intermittent lameness of the right front
leg when exercised.There is pain in the proximal interphalangeal
joint. Radiographs of this region show multiple, small, radiolucent
subchondral bone defects in the distal first phalanx, accompanied
by a narrowed joint space and mature periarticular osteophytes.
The radiographic changesare most likely those of:
A. Severe,chronic, degenerativejoint disease.
B. Osteochondrosis.
C. Acute, active septic osteoarthritis.
2. A focal area of solid, ovoid calcification is identified in the soft
tissuespalmar and slightly proximal to the proximal border of the
navicular bone on the lateromedial view of the foot of a 10-year-
old Quarter horse gelding. What additional radiographic projection
would provide the best image to determine whether this calcifica-
tion is within the collaterai cartilage of the distal phalanx or the
deep digital flexor tendon?
3. What are three common radiographic signs seenwith chronic
laminitis?
4, A 10-year-oldArabian cross-breedmare is presentedwith
lameness and swelling along the lateral aspect of the left front
pastern. The owner reports the duration of both the lamenessand
the swelling to be about 10 days. Radiographs of the region show
a smooth-surfacedperiosteal opacity arising from the lateral cortex
of the proximal phalanx. What factors should be considered in
determining the significance of the radiographic findings?
5. A 4-year-old Thoroughbred stallion in race training develops
an acute lameness in the left front foot. On a dorsal 65-degree
proximal palmarodistal oblique view of the distal phalanx, a linear
radiolucency is noted extending from the solar margin at the lateral
quarter into the body of the bone. What are your rule-outs, and
what additional information (or radiographic projections) would
be useful in making the diagnosis?
6. What steps should be taken before radiography of the distal
phalanx to achieve the best-quality images?
7, A l2-year-old Arabian gelding is presented for a precompeti-
tion physical examination (horse does competitive trail riding).
The horse has not competed for 2 years becauseof problems with
"tytttg-op slmdrome." During the past 2 yearc,the horse has been
used for riding lessons, with no reported lameness. On physical
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
with hoof testers. Figure 23-33A to C presents the lateral and
dorsal 65-degreeproximal-palmarodistal oblique views of the right
front foot (radiographs ofthe contralateral foot appearedsimilar).
Identift the abnormal radiographic signs,and make your diagnosis.
8. A l7-year-old Quarter horse stallion has been lame for 5 days,
with frequent periods of laying down. The horse is not responding
to symptomatic treatment for laminitis. On physical examination,
the horse is lame on both front feet but more on the left. There is
soft-tissue swelling around the left coronary band. Identifr the
radiographic abnormalities in Figure 23-3M and B, and make
your diagnosis.
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
block done to aid working with the foot relieved the lameness.A
sole abscesswas found at the toe. It was opened for drainage and
appeared to dissect into both medial and lateral sole areas. The
foot was soaked and packed. Three days later, the filly was some-
what better but still lame. Radiographs were made at this time
(Fig. 23-35A to C). Describe the radiographic changes,and make
your diagnosis.
10. A 4-month-old Quarter horse colt was presentedfor evaluation
of chronic enlargement of the left fore foot distal to the fetlock
without lameness.Physically,there was a nonpainful swelling cir-
cumferentially around the left front pastern and a firm prominence
along the dorsal surface of the joint. Describe the radiographic
abnormalities in Figure 23-36A and B, and make your diagnosis.
Answers begin on page 727.
 The Phalanges 293

@ll il@lll
i110u,..,ii:1u

Figure 23-33. Lateromedial(AJand dorsal65-

degreeproximal-palmarodistal views 18 and C/ of
the di stal phal anxof a mi l dl y l ame 12-yea r-ol d
A rabi angel di ng.

Figure 23-34. Lateromedial/,4/and dorsopalmar/B/

views of the left front foot of a 17-vear-oldOuarter
h o r s es t a l l i o nl.a m ef o r 5 d a vs.
294 S KE L ET ON -EOU IN E
A P P E NDI CU L AR

Figure 23-35. Lateromedial (A), horizontal

beam dorsopalmar(B), and dorsal 6S-degree
proximal-palmarodistal /C/ views of the distal
phal anxof a 2-month-ol dB el gi an-P ercheron
fi l l yw i th a severeri ghrhi ndl egl ameness.

Figure 23-36. Lateromedial(A) and dorcal (B) 45-

degree proxi mal -pal marodi stal
obl i quev i ew s of the
left front phalangesof a 4-month-oldOuarter horse
colt with enlargementdistal to the fetlock, but no
l ameness.
 CHA P T E R
24
The Navicular Bone
I Robert L. Toal
I Anatomy
The normal radiographic anatomy of the navicular bone is shown
in Chapter 50. The distal sesamoid or navicular has two surfaces
(flexor and articular), two borders (proximal and distal), and two
extremities. The navicular bone ossifies from a single center (Fig.
24-1).r There are two separatehyaline cartilage-covered articular
surfaces.The larger "proximal" articular surface conforms to the
condylesof the middle phalanx. A smaller "distal" articular surface,
associatedwith the distai navicular border, is essentiallya narrow
facet that articulates with the distal ohalanx. The distal articular
surface of the navicular bone and the articular surface of the distal
phalanx are usually parallel but can be convergent.' The flexor
surface has a prominent central ridge-the central eminence. The
deep digital flexor tendon and adjacent bursa contact the fibrocar-
tilage-coveredflexor surface.The navicular bone is held in position
by three strong ligaments. The paired suspensory navicular liga-
ment originates from the dorsolateral aspects of the proximal
phalanx and attaches to the proximal navicular border and both
extremities.The distal sesamoidean,or impar, ligament originates
from a projection on the distal navicular border just caudal to the
articular surface.The impar ligament inserts on the distal phalanx
deep to the deep digital flexor tendon (seeFig.23-7). Blood vessels
and sensory nerves traverse these ligaments and ramifr into the
navicularbone and sprovial membranevia both borders.3There is
no evidence of an anatomic communication between the distal
interphalangealjoint and the navicular bursa.a
I Indications for radiography
Indications for navicular radiography include the assessmentof
bony changesin navicular slmdrome, the identification of signifi-
cant bone abnormalitiesduring pre-purchaseexamination,the as-
sessment of bone or bursal involvement in foot wounds or ab-
scesses,the evaluation of suspectedtrauma, and the collection of
information about the morphologic progressionor remission of
navicularbone abnormalities.
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
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 .
for radiosraphic
I #ffjfi:on
Accurate radiographic evaluation of the navicular bone depends on
a radiograph that is properly positioned and exposedand on a
foot that is free of distracting artifacts. Proper preparation for
navicular radiography is similar to that for the distal phalanx
discussed in Chapter23.
Positioning aids, such as a reinforced cassette,grooved wooden
blocks, and a cassettetunnel, assist in radiographic evaluation of
the navicularbone (Fig. 24-2).tJseofa grid for angulardorsoprox-
imal-palmarodistal views is optional. A grid improves radiographic
detail by reducing film fog from scatter radiation. Becausethe grid
is fragile, its use is limited to techniques during which the foot
does not bear weight directly on the grid.
I Radiographic views
The location of the navicular bone and its complex shape require
that at least three different views be made for complete radio-
graphic evaluation. Theseviews include the angular dorioproximal-
palmarodistal views, the lateromedial view, and the palmaroproxi-
mal-palmarodistal oblique view (Tabie 24-1)., The dorsopalmar
view is an additional view that is helpful for evaiuating the extremi-
ties of the navicularbone.
Dorsoproximal-palmarodistal views
Angular dorsoproximal-palmarodistal views of the navicular bone
may be made by two very different hoof-positioning techniques.s7
Thesemethods include (1) the high coronary stand-on route-the
foot stands directly on a reinforced cassette,cassettetunnel, or
grooved wooden block. The x-ray beam is centered just proximal
to the coronary band and angled 45 or 65 degreesproximally from
horizontal; and,(2) the upright pedal route-the hoof rests on the
toe in tiptoe fashion, with the dorsal hoof wall positioned either
80 or 90 degreesfrom horizontal; the x-ray 6eam is directed
horizontally (Fig. 2a4).
, Z
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 .

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
flexorsurfaceof thenavicularbone.
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.
Palmaroproximal-palmarodistal view
The palmaroproximal-palmarodistalview (Fig. 24-4) projects the
flexor cortex, medulla, and central eminence. The concept is to
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
bearing weight.' Paradoxically,some people prefer that the foot be
more slightly forward than in the normal standing position.qn
Regardless of foot location,the primary beam is positionedtangen-
tial to the estimated plane of the flexor cortex and is centered
between the bulbs of the heel. Too steep of a beam angle with the
foot may result in superimposition of the ergot over the navicular
bone. Reduced angulation alters the apparent width of the flexor
cortex and results in an indistinct interface between cortical and
trabecular bone.8Oblique palmaroproximal-palmarodistalprojec-
tions distort the navicular shape and superimposeit behind the
paimar processes of the distal phalanx.
Dorsopalmar view
In the dorsopalmar view, the x-ray beam is directed horizontally
toward the hoof, which is in a normal weight-bearing position.
The foot should be placed on a wooden block to allow the cassette
to straddle the hoof and the navicular bone. This view is not done
routinely but is useful in evaluating the extremities of the navicular
bone, particularly when subtle abnormalitiesare suspected.
I Normal radiographic
I 3 and lB years of age, with a peak incidence of 9 years of age at
r appearance
In the angular dorsoproximal-palmarodistal views, the navicuiar
bone is of uniform radiopacity. Its spindle shape varies somewhat
from horse to horse. The extremities are fairly symmetric and are
bluntly pointed. The proximal border is smoothly marginated. The
shapeof the proximal border has been classifiedvariously as con-
cave, undulating, straight, or convex.l0 The distal border has a
variable number (usually no more than seven) of cone-shaped
radiolucencies.Their sizeis variable, with the height being approxi-
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,
crescent-shapedradiolucency may be seen within the cortex of the
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
to a trabecular bone island interposed between two parallel cortical
bone platesof the centraleminence.lr,LThe endsofboth extremit-
ies are rounded, being variably superimposedover the palmar
processesof the distal phalanx. The articular surfaceis occasionally
seen in this view (see Fig. 50-62).
I Navicular disease
The term nayicular diseaseis used in this discussion to denote a
chronic progressive syndrome involving the navicular bone, its
fibrocartilaginous flexor surface, its ligaments and capsular attach-
ments, the deep digital flexor tendon, and the navicular bursa. The
distal interphalangeal joint may be involved to a lesser degree but
its role in this syndrome is controversial. The precise source of
pain in navicular lameness remains obscure. Variable resDonseto
local analgesiaof the medial and lateral palmar digital nerves, the
distal interphalangealjoint space,and the naviculaibursa is noted.
This variable responsesuggeststhat sensory nerves innervating the
s1'novial membranes of the collateral sesamoideanligament, the
distal sesamoideanimpar ligament, and the navicuiar bone itself
play a separate or combined role in mediating pain in navicular
disease.a'13 In addition, it has been shown that pain arising from
the dorsal margin of the sole can be attenuated by analgesiaof the
distal interphalangealjoint or palmar digital nerve block.raThis
further complicates the interpretation of nerve block results in
horses suspectedof having navicular origin pain.
Navicular diseaseis primarily a slowly developing, intermittent,
bilateral forelimb lamenessls,16;it is occasionallyrecognized in the
hindlimb.l? In general, navicular diseaseis most common between
presentation. Males are more involved than females, geldings have
a greater risk than stallions, and the breed prevalence varies ac-
cording to the population characteristicsof the reporting institu-
ti ons .18,Ie
There are no pathognomonic clinical testsfor navicular disease.
The diagnosisis basedon a characteristicgait, localizationof pain
to the caudal part of the heel, identification of radiographicsigns
of naviculardegeneration,and elimination of other causesof lame-
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
even if clinical signs are not.
The pathophysiology of navicular syndrome is multifactorial'
Classically,it has been characterizedas navicular fibrocartilaginous
degeneration with secondary tendon fibrillation. Palmar cortex
bone erosions can develop later.s'rs'20'21
Other bony changesinvolv-
ing the distal border foramina (enlargement) have also been
noted.2l "Abnormalities such as dilated vessels,vascular thrombo-
sis, granulation tissue, and empty synovium-lined invaginations
2e
have been observed histologically to a variable degree.3'2O It is
unknown whether these findings represent a continuum of events
or are separate,isolated abnormalities. Enthesopathy involving the
ligaments of the proximal and distal borders can occur either with
or without distal border foramina changes.Many of the gross and
histologic features of navicular syndrome suPport the concept of
a degenerativearthrosis."'27'2e-3r There is some evidencethat
chronic passivevenous congestion of the foot is related to navicular
changesof elevatedsubchondral bone pressure and arterial hyper-
32'33
emia,27'
Similar confusion exists concerning the significance of radio-
graphic changes in the navicular bone in horses with lameness
attributed to navicular disease.It has been shown that there is a
poor correlation of pathologic and radiographic findings with clini-
cal signs and prognosis.t9'24'26'28'3a Horses without radiographic
abnormalities may have clinical navicular lameness, and horses
with pathologic and radiographic changesmay be sound.'& " This
paradox is explained in part by the fact that horses have different
pain thresholds, are subjected to wide ranges of physical exercise,
and are evaluated in variable stagesof disease.sAdditionally, some
pathologic changes may represent insignificant wear lesions or
may be located in tissues of soft-tissue opacity and thus are not
radiographically discernible.'o''u Sevetal authors agree that radio-
graphic signs of navicular diseasein an otherwise clinically normal
horse are significant and may warrant a cautious prognosis for
future soundness.8'36 However, there is no universal agreement
as to the clinical significance of all radiographic signs seen in
navicular disease.
Radiographic signs of navicular degeneration
Radiographic abnormalities associatedwith navicular degeneration
are varied. Bony abnormalities may occur separately but usually
they occur in combination, unilaterally or bilaterally. Their clinical
relevancewith respect to presence,absence,or degree of lameness
in a given animal is varied.taAdditionally, there is no clear associa-
tion betlveen changesin the radiographic appearanceof navicular
bones and clinical outcome following treatment.3TThus, radio-
graphic changesof navicular degeneration must be interpreted in
context with the presenting clinical signs. This is similar for other
musculoskeletalconditions.
The major radiographic signs of navicular degenerationare
shown in TabIe 24-2. A diagram depicting various radiographic
Table 2tl-2- Roentgen signs of navicular degeneration
Proximal border and extremities
Enthesophytes
Spurs on extremities
Remo de ling
Distal border changes
Synovial invaginations
Small osseousfragments
Flexor cortex changes
Corticalerosions
Mineralizationof deep digital flexor tendon
Medullary cavity changes
Radiolucentcvsts
Sclerosis
signs of navicular degeneration is shown in Figure 24-5. Radio-
graphic manifestations of navicular degeneration and normal vari-
ants are shown in Figures 24-6 throrgh 24-9.
Proximal border and navicular bone extremities
The heredity aspectsof the shape of the proximal navicular border
and its relationship to risk for navicular symdrome have been
studied in Warmbloods.ro It was concluded that a convex-shaped
proximal border showed the least risk for development of severe
naviculardisease.
Dystrophic mineralization at sites of ligamentous or tendon
attachment is termed enthesophytosis.2e, 38 Mineralization of the
suspensory navicular ligament along the proximal border results
in a roughened or sawtoothed appearance of the bone margin.
Pronounced enthesophyteson the extremities of the navicular bone
have been termed spurs. When enthesophytosis is excessive,the
overall shape of the bone is altered. This is called remodeling (see
Figs.24-68 and C, and Fig.2a-7).
In general, enthesophl'tes are manifestations of a degenerative
process.s'rs'38'3eThey are occasionally seen in non-lame animals,
particularly in older, heavily worked animals.'&2a'26Enthesophl.tes
in younger horses and extensiveenthesophltes in others should be
considered significant, particularly if accompanied by lameness.
Enthesophytesare best seen in angular dorsoproximal-palmaro-
distal views as new bone formation on the extremities or as bone
proliferations along the proximal border (sawtoothed border) (see
Ftg. 2a-7A). In the lateral view excessiveremodeling gives the
bone an elongated appearance(seeFig. 24-78). Caution should be
exercised because improperly positioned lateral views may arti-
factually distort the bone profile. Similarly, normal variants exist
that resembie remodeling laterally when angular dorsoproximai-
palmarodistal images are normal.2e
Distal border changes
The radiolucent invaginations along the distal border ofthe navicu-
lar bone are called synovial invaginations. These are best seenin the
dorsal 65-degree proximal-palmarodistal view. They are normally
inverted cone to popsicle stick in shape.Increasedsize and number
are physiologic changesrelated to type and frequency of work.a'
A change in shape to a lollipop or mushroom shape is considered
to signal an abnormal degenerativechange(seeFig.24-7c).2e'3o'40
These abnormal synovial invaginations may be a sign of arthrosis
of the distal interphalangeal joint, albeit a navicular manifestation.
The presence of synovial invaginations in the extremities of the
navicular bone has been considered abnormal by some but they
do not correlate with lameness.3a
Horses with clinical navicular diseasehave a high incidence of
abnormal s1'novial invaginations but their clinical specificity re-
mains uncertain. This is because lollipop-shaped qmovial invagi-
nations have been reported rn llo/o of normal horses, and there is
no correlation with degree of lameness in confirmed navicular
lameness.3a
Radiolucent changes of the distal border cannot be seen well
in lateromedial views. The palmaroproximal-palmarodistal view,
however, projects them end on within the trabecular portion of
the bone. Increasesin size of visible fossaein this view are abnor-
mal (see Fig.24-9A).8,e The range of normal shape variation of
fossae for this view, however, has not been established.It is the
author's opinion, therefore, that distal border radiolucent changes
are more consistently evaluated with angular dorsoproximal-pal-
marodistal views, especially when there is only minimal enlarge-
ment.
Mineralization associatedwith the distai sesamoideanimpar liga-
ment is another degenerative change. The significance of this is
similar to that of enthesophltes involving the proximal border.
Occasionally, osseous fragments can be seen associatedwith the
distal border. These can be seen in normal and lame horses alike.
Small osseousfragments occasionallyindicate chip fractures of the
 The NavicularBone 299

D O R S A L6 5 ' P R O X I M A L . L A T E R O M E D I A L P A L M A R OPR OXIM AL .

PALMARODISTAL VIEW VIEW P A L M A R OD ISTAL
VIEW

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-
ular fractures. Small osseousfragments of the distal border are best
seen in the angular dorsoproximal-palmarodistal views.
Flexor coftex Ghanges
Gross pathologic involvement of the navicular flexor fibrocartilage
is varied. Lesions include yellowish discoloration, cartilage thin-
ning, focal erosions, and cartilage ulcerations, with or without
subchondral bone involvement.5'26't0 Some of the abnormalities
may be age-relatedphenomena, but all have been seen in navicular
diseaseto varying degrees.'n''u
Bursa, tendon, and cartilage changesare not usually seen radio-
graphically; only subchondral bone defectsare routinely detectable.
Early lesions are best seen on the palmaroproximal-palmarodistal
view whereas severe defects may be recognized in other views
as well. A reliable radiographic sign consists of focal or diffuse
subchondral bone corticai lysis (see Fig. 24-9).8 Flexor cortex
erosions are rarely seen in sound horses and have a significant
correlation to the presenceand desree of lameness.''23'3aIt is not
unusual for large flexor cortical erosions to simulate medullary
cystlike lesions in the dorsopalmar view. It is important to localize
such cyst-like lesions radiographically. Flexor cortical erosions are
often associatedwith tendinous adhesions,whereasmedullary cysts
are not.30'38This added information mav be imoortant in the
overail management of the animal. Naviiular va;iants of a flat
central eminence and a crescent lucency within the cortex of the
centrai eminence exist (see Fig. 24-B). These are normal variations
and should not be misdiagnosed as navicular degeneration. Well-
positioned lateral radiographs depict the flexor cortex in profile
axially. Minor dimpling of the central eminence in this view may
be a normal variant or may be the result of geometric distortion.
Abrupt irregular cavitations are abnormal (see Fig. 24-6D). It is
recommended that abnormalities of the flexor cortex observedon a
lateral radiograph be further evaluatedusing the palmaroproximal-
palmarodistal view.
Dystrophic mineralization of the deep digital flexor tendon may
be seenin conjunction with flexor erosions.This finding is reported
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 .

Figure 2tl-9. Palmaroproximal-palmarodistal views of the navicularflexor cortex and medullashowingvariousabnormalitles.
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
prognosis.rT'a\Faint visualizationof the deep digital flexor tendon
on the lateral view is a frequent normal finding. Diseasedtendons
that are sufficiently mineralized may be seen in both lateral and
palmaroproximal-palmarodistal views.
Medullary cavity changes
Medullary trabecular disruption in the form of trabecular lysis or
cyst-like cavitations is abnormal. This is rarely seenin sound horses
(seeFig. 24-7D). Theseradiolucenciesmay be seenon the angular
dorsoproximal-palmarodistal, palmaroprorimal-palmarodistal, and
occasionally lateral views. They range in size from 0.5 to 1.5 cm
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
superimposed over the navicular bone. By evaluating other views
or by repeating the dorsoproximal-palmarodistal view at a different
angle,it is possibleto seeif the suspectlesion changesin position
or remains associatedwith the navicular bone. Similarly, lucent
artifacts that result from air trapped in the frog by packing material
may be misinterpreted as radiolucent bone lesions. Air pockets
usually present as linear radiolucent shadows.When there is doubt,
the frog should be repacked.
Extensive erosions of the flexor cortex can falsely mimic medul-
Iary cavity cysts on angular dorsoproximal-palmarodistal views. On
a palmaroproximal-palmarodistal view, the suspect lesion can be
localized as to whether it originates from the flexor cortex or the
medullary caviry (see Fig. 24-9C and D).
Sclerosisof the medullary spongiosais said to be an early finding
in horseslame becauseof navicular disease.', 8'31This is seenas a
fine trabecular pattern that blends with the flexor cortex, resulting
in an indistinct interface between the flexor cortex and the medul-
lary spongiosa.',8This finding is not reliablebecauseit can often
be seenin normal horsesas a result of a poorly positioned radio-
graph (seeFig. 24-BP1.\ z+'+2, ez
Normal radiographic findings
It should be realized that many horses with clinical navicular
lamenesshave normal radiographs.l'gThese animals may have dis-
easethat better falls into the category of navicular bursitis. Before
this conclusion is reached, however, an adequate number of high-
quality radiographs should be obtained.
The N avi cu lar
Bone 3O l
*4l$i
A, En face view of enlargeddistal
subchondral bonescl erosi s.
Thi sw as al soseenon othervi ew s.
ee'Technetium bone scintigraphy
is an extremely valuable ad-
junct when radiographic findings are equivocal, or when the bone
is normal but diseaseof the navicular soft tissuesis susoected.
This is true because nuclear scintigraphy is more sensitive than
radiography in identifizing early soft-tissue and bone abnormalities,
although a scintigram provides primarily physiologic as opposed
to anatomicinformation. Becausephysiologicalterationsassociated
with navicular degeneration are likely to precede gross anatomic
changes,scintigraphy of the navicular bone should be done when
clinical signs are compatible with navicular lameness but radio-
graphs are normal.aa
I Fractures
Navicular fractures are infrequently reported. Therefore, data are
not available from which to draw firm conclusions about their
incidence and pathophysiology. Most navicular fractures are trau-
matic or pathologic in origin. Both chip and complete fracture
types have been described. A diaeram of navicular fractures is
s h o w n i n F i g u r e2 4 - 1 0 .
Care should be taken to avoid misinterpreting artifacts as navicu-
lar fractures. The sulci of the frog may cast overlying radiolucent
shadowsin the dorsoproximal-palmarodistal projection that simu-
late complete navicular fracture. This situation occurs when the
foot is unpacked or when air is trapped in the sulcus by packing
material. Sulcal lines typically extend beyond the periphery of the
navicular bone. Complete fractures are confined to the bone and
are seen on dorsoproximal-palmarodistal and palmaroproximal-
palmarodistal views. Gravel or debris in the foot, or a foot with
scaly horn may simulate chip fractures. Through proper hoof
preparation (cleaning,paring, and packing), these artifacts can be
eliminated. Lateral views or dorsoproximal-palmarodistal radio-
graphs made at different angles help to localize a suspect opacity.
When in doubt about navicular fractures, the hoof should be
cleaned and repackedbefore more radiographs are made.
Osseous fragments of the distal border
Small osseousfragments associatedwith the distal border of the
navicular bone and impar ligament are occasionallyseen. These
osseousbodieshavemore than one pathogenesis. They may be due
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

mineralization, separate centers of ossification within the impar

ligament, or synovial osseousmetaplasia.3l'"When present,osse-
ous bodies may be unilateral or bilateral, may involve both the
medial and lateral aspects of the bone, or may involve only one
side of the bone. Larger fragments are most often found on the
medial side of the bone.
Osseousbodies that are true chip fractures may appear as small
(0.2 to 1.2 cm), rectangular bone fragments separated from the
distal border by a radiolucent zone. A fracture bed within the
navicular bone corresponding in size and shape to the fragment is
often seen." Dystrophic mineralization of the impar ligament may
have a similar appearance,but a fracture bed is not seen.
The presenceof osseousbodies does not alwaysindicate navicu-
lar disease,but an association has been noted by some investiga-
tors.23These bodies have not been shown to influence clinical signs
or prognosis of navicular disease(Fig. 24-Il).

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-

BWP ation. This circumstance has two plausible explanations. One is

that there has been a pathologic fracture of a primarily diseased
bone. Another is that fracture or multiole ossification centers are
present initially. The resultant instability causeschronic secondary
degenerativechanges.Thus, when a multipartite sesamoidnavicular
bone is seen in conjunction with severe degenerative navicular
changes,it is diffrcult to determine whether the navicular bone is
fractured or multipartite (seeFig. 24-l2B).

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-

Figure 2/t-12, A, Completenavicular
hnne {rae-rr.oc R Trina.tiia navicula.
b o n e ,w h i c hi s p r o b a b lyco n g e n itaini o r i-
gin.
graphs are negative, a fistulogram or radiograph made following
insertion of a blunt probe should be considered.This examination
aids in establishing if the puncture wound involves the navicular
bursa or bone (Fig. 24-13). This is important becausea puncture
wound that involves a bone or bursa warrants a more cautious
prognosis and more vigorous therapy because osteomyelitis may
result. A negative fistulogram does not eliminate the possibility
that the navicular bone or bursa was involved in the initial injury
because partial tract healing in the deeper areas of the wound
could prevent passageof contrast medium during fistulography,
resulting in a falsely negative study.
Regardlessof whether a fistulogram is done during the initial
evaluation, follow-up radiographs should be taken within the sub-
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
have initially negative radiographs subsequently develop radio-
graphic signs of bone infection. Once present, navicular osteomyeli-
tis may progress and result in serious complications, leading to
chronic lamenessthat may eventually necessitateeuthanasia.
Of the standard projections to evaluate the navicular bone, the
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
Figure 24-13- Fistulogramafter a nail puncturewound. There is communi-
c a t i o no f t h e t r a c tw ith th e n a vicu labr u r sa .
The NavicularBone 3O3
disruption and irregularity of the flexor surface. These lesions are
initially located abaxial to the central eminence. The greater the
duration of the injury without treatment, the more extensive the
diseasein terms of depth of the irregularity into the navicular bone
and the abaxial extent of it.
More severechronic findings associatedwith puncture wounds
and navicular osteomyelitis include septic arthritis of the distal
interphalangeal joint (Fig. 24-14), secondary joint disease,patho-
iogic fracture of the navicular bone, and subluxation of the distal
interphalangeal joint. Rupture of the deep digital flexor tendon or
navicular impar ligament causessubluxation of the distal interpha-
langealjoint. In some horses,degenerativechangessimilar to those
seenin navicular diseasehave been observedas long-term sequelae.
I Miscellaneous conditions
Another condition that affects the navicular bone is degenerative
arthritis. The navicular bone participates in forming the distal
interphalangeal joint. The articular border of the navicular bone
adjacent to the middle phalanx is normally rounded. Periarticular
osteophltes can be seen that result in subtle, pointed, spur-like
Figwe 2/t-14. Lateralforefoot of a young horse 4 wee[.s after a nai
punctureof the navj cul arbursa.Therei s septi carthri ti o{
s th e di s ta rnterphal an-
gealj oi nt,osteol ysi sand di spl acement of the navi cul ar
bo ne,and dy s trophc
mi neral i zati on
of the deepdi gi talfl exortendon.
3 O4 A P P E NDI CULASRKE L ET ON -EOU IN E

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
Droiections.These have been seen in normal horsesas well as in
Lorseslame from navicular disease;thus their significanceis uncer-
tain. Reports of significant pathologic processesinvolving the artic-
ular cartilage in navicular diseaseare rate.26It is believed, however,
that some ihuttg.t seen in navicular degeneration are a form of
27'2e
distal interphalangealjoint arthrosis.26'
Congenital absence of the navicular bone (agenesis)has been
reDorteo.--'--
References
1. Getty R: Sisson and Grossman'sThe Anatomy of the Domestic Animals. Philadel-
phia, WB Saunders,1975.
2. Kaser-Hotz B, Ueltschi G: Radiographic aPpearance of the navicular bone in
sound horses. Vet Radiol Ultrasound 33:9, 1992.
3. Colles CM, Hickman l: The arterial supply ofthe navicular bone and its variations
in navicular disease.Equine Vet .l 9:150, 1977.
4. Bowker RM, Ruckershouser Sl, Kelly BV et al: Immunocltochemical and dye
distribution studies of neryes potentially desensitized by injections into the distal
interphalangeal ioint of the navicular bursa of horses. I Am Vet Med Assoc 203:1708'
1993.
5. Oxspring GE: The radiology of navicular diseasewith observations on its pathol-
ogy. Vet Rec 15:1434,1935.
6. Canpbell ]R, Lee R: Radiological techniques in the diagnosis of navicular disease'
Equine Vet I 4:135, 1972.
7. Watrous BJ: A Guide to Equine Field Radiography. Trenton, Nt, Veterinary Learn-
ing Systems,1995,p 13.
8. O'Brien TR, Millman TM, Pool RR, et al: Navicular diseasein the Thoroughbred
horse: A morphologic investigation relative to a new radiographic projection' I Am
Vet Radiol Soc 16:39,1975.
9. Rose RJ, Taylor BJ, Steel JD: Navicular diseasein the horse: An analysis of seventy
casesand assessmentof a special radiographic view. I Equine Med Surg 2:492,1978'
10. Dik K, van den Broek J: Role of navicular bone shape in the pathogenesis of
navicular disease:A radiological study. Equine Vet I 271390' 1995
I1, Poulos R Brown A: On navicular disease in the horse: A roentgenological and
patho-anatomic study: I. Evaluation of the flexor central eminence Vet Radiol 30;50,
1989.
12. Berry C, Pool R, Stover S, et al; A radiographic/morphologic investigation of a
radiolucent crescent within the flexor central eminence of the navicular bone in the
Thoroughbred. In Proceedings of the American College of Veterinary Radiology
Annual Meeting, Nov 29 Dec 1, 1990, Chicago.
13. Dyson S], Kidd L: A comparison of responsesto analgesiaof the navicular bursa
and intra-articular analgesia of the distal interphalangeal ioint in 59 horses. Equine
Vet l 25: 93, 1993.
14. Schumacher J, Steiger R, Schumacher ], et al: Effects of analgesia of the distal
interphalangeal joint of palmar digital nerves on lameness caused by solar pain in
horses. Vet Surg 29:54, 2000.
15. Stashak TS (ecl): Adam's Lamenessin Horses,4th ed. PhiladelPhia,Lea and
Febiger,1987,p 499.
16. Rose RJ: The treatment of navicular disease-a review and current concepts' Paper
presented at the 29th Annual Convention of the American Association of Equine
Practitioners, December 1983, Las Vegas,Nevada,
17. Valdez H, Adams OR, Peyton LC: Navicular diseasein the hindlimbs ofthe horse'
I Am Vet Med Assoc 172'.291,1978.
18. Ackerman N, Johnson ]H, Dorn CR: Navicular diseasein the horse: Risk factors,
radiographicchanges,and responseto therapy.I Am Vet NIed Assoc 170:183'1977'
19. Wright IM: A study of 118 casesof navicular disease:Clinical features. Equine Vet
I 2 5 :4 8 8 ,1 9 9 3 .
20. Pool RR, Meagher DM, Stover SM: Pathophysiology of navicular syndrome Vet
Clin North Am Equine Pract 5:109, 1989.
21. Wilkinson GT: The pathology of navicular disease.Br Vet I 109:38, 1953.
22. Smith F: The pathology of navicular disease.Vet I 23:72, 160' 242, 1886.
23. Wright lM, Kidd l, Thorp BH: Gross histological, histomorphometric features of
the navicular bone and related structures in the horse. Equine Vet J 30:220, 1998'
24. Colles CM: Ischaemic necrosis of the navicular bone and its treatment Vet Rec
104:133,1979.
25. Fricker CH, Riek W, Hugelshofer J: Occlusion of the digital arteries: A model for
pathogenesisof navicular disease.Equine Vet J 14:203' 1982.
26. Doige CE, Hoffer MA: Pathologic changes in the navicular bone and associated
structuresof the horse. Can J Comp Med 47:387,1983.
27. SvalastogaE: Navicular disease in the horse: A microangiographic investigation.
Nord Vet Med 35:131,1983.
28. Ostblom L, Lund C, Melsen F: Histologic study of navicular bone disease.Equine
Vet J 14:199,1982.
29. Poulos PW Smith MF: The nature of enlarged "vascular channels" in the navicular
bone ofthe horse.Vet Radiol 2:60, 1988.
30. SvalastogaE, Reimann I, Nielsen K: Changes of the fibrocartilage in navicular
diseasein horses.Nord Vet Med 35:373,1983.
31. SvalastogaE, Neilsen K: Navicular diseasein the horse: The slnovial membrane
of bursa podotrochlearis.Nord Vet Med 35:28, 1983.
32. SvalastogaE, Smith M: Navicular disease in the horse: The subchondral bone
pressure.Nord Vet Med 35:31, 1983.
33. Colles CM: Concepts of blood flow in the aetiology and treatment of navicular
disease.Paper presented at the 29th Annual Convention of the Anerican Association
of Equine Practitioners, December 1983, Las Vegas,Nevada.
34. Wright IM: A study of 118 casesof navicular disease:Radiological features.Equine
Vet I 25:493, 1993.
35. Turner T, Kneller S, Badertscher R, et al: Radiographic changes in the navicular
bones of normal horses. In Proceedingsof the 32nd Annual Meeting of the American
Association of Equine Practitioners, 1986, p 309.
36. Huskamp B, Becker M: Diagnose und prognose der rontgenologischen Verander-
ungen an den Strahl-beinen der Vordergliedma Ben der Pferde unter besonderer
Berucksichtigung der Ankau fsuntersuchung: Ein Versuch zur Schematisierung der
Befunde.PraktischeTierarzt 61:858,1980.
37. Wdght IM: A study of 118 cases of navicular disease: Treatment by navicular
suspensorydesmotomy.Equine Vet I 25:501,1993.
38. Poulos P, Brown A, Brown E, et al: On navicular diseasein the horse: A roentgeno
logical and patho-anatomic study: II. Osseous bodies associated with the impar
ligament.Vet Radiol 30:54, 1989.
39. Turner TA: The anatomic, pathologic, and radiographic aspects of navicular
disease.Comp Contin Educ Pract Vet 4:350, 1982.
40. MacGregor C: Radiographic assessmentof navicular bones based on changes in
the distal nutrient foramina. Equine Vet I 18:203, 1986.
41. Tumer 1A: Dystrophic calcification of the deep digital flexor tendons resulting
from navicular disease.Vet Med Small Anim Clin 77:571, 1982.
42. Ruohoniemi M, Teruahartiala P: Computed tomographic evaluation of Finnhorse
cadaver forefeet with radiographic problematic findings on the flexor aspect of the
navicular bone. Vet Radiol Ultrasound 40:275,1999.
43. Widmer W, Buckwalter K, Fesslerl, et al: Use of radiography, computed tomogra-
phy and magnetic resonance inaging for evaluation of navicular slmdrome in the
horse.Vet Radiol Ultrasound 41:108,2000.
44. Trout DR, Hornof WJ, O'Brien TR: Soft-tissue and bone-phase scintigraphy for
diagnosis of navicular diseasein horses. J Am Vet Med Assoc 198:73, 1991.
45. van De Watering CC, Morgan JP: Chip fractures as a radiologic linding in
navicular diseaseof the horse. J Am Vet Radiol Soc 16:206, 1975.
46. Lillich lD, Ruggles AJ, Gabel AA, et al: Fraclure of the distal sesamoid bone in
horses:17 cases(1982-1992).I Am Vet Med Assoc2071924,1995.
47. Vaughan LC: Fracture ofthe navicular bone in the horse. Vet Rec 73:895, 1961.
48. Arnbjerg J: Spontaneous fracture of the navicular bone in the horse. Nord Vet
Med 31:429,1979.
49. Reeves MJ: Miscellaneous conditions of the equine foot. Vet Clin North Am
Equine Pract 5:221, 1989.
50. Smlthe RH: Fracture of the navicular bone in the horse-comment. Vet Rec
73:1009,1961.
51. Kaser-Hotz B, Ueltshci G, Hess N, et al: Navicular bone fractures in the pelvic
limb in two horses. Vet Radiol Ultrasound 32:283,1991..
52. Rick MC: Navicular bone fractures. In White NA, Moore lN (eds): Current
Practice of Equine Surger,v Philadelphia, JB Lippincott, 1990, pp 602 605.
53. Richardson GL, O'Brien T: Puncture wounds into the navicular bursa of the
horse: Role of radiographic evaluation. Vet Radiol 26:203,1985.
54. Reid CF: Radiology panel-film interpretation sessionnotes. In Proceedings of the
22nd Annual Convention of the American Association of Equine Practitioners, 1976,
Dallas, Texas.
55. Modransky C, Thatcher C, Welker F, et al: Unilateral phalangeal dysgenesisand
navicular bone agenesisin a foal. Equine yet J 19,347, 1987.
 The NavicularBone 3O5

re Ouestions palmarodistal views either can be within the navicular spongiosa

1. The suspensory navicular ligament attaches to which of the
following:
A. The flexor surface
B. The flexor and articular surfaces
C. The proximal border and extremities
D. The distal border and flexor surface
E. None of the above
2. The best radiographic projection for obtaining a true unob-
structed view of the distal border of the navicular bone is the
A. Palmaroproximal-palmarodistal.
B. 65-degreedorsoproximal-palmarodistal.
C. 45-degreedorsoproximal-palmarodistal.
D. Dorsopalmar view.
E. None of the above.
or may represent a focal flexor cortical lytic lesion.
6. Osseousfragments of the distal border of the navicular bone
are due to which of the following?
A. Chip fractures
B. Impar ligament mineralization
C. Separateossification centers
D. Synovial osseousmetaplasia
E. All of the above
7. True or False.Congenital multipartite sesamoidsand complete
navicular fractures can alwaysbe differentiated radiographically.
8. When complete navicular fractures occur, why do they heal
with a fibrous rather than an osseousunion?

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.
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NECK AND THORAX-
COMPANIONANIMALS
CHA P T E R
25
lnterpretation Paradigms for the
Small Animal Thorax
. Clifford R. Berry . Nancy E. Love
I Radiographic interpretation
I of the small animal thorax
Overview and objectives
Radiographicevaluation of the small animal thorax is one of the
most important and most frequentiyperformed diagnostictestsin
smail animal practice.t3 Important information about major medi-
cal problems, such as heart diseaseand cancer, is often obtained
from thoracic radiographs.Follow-up radiographscan be used to
evaluateresponseto therapy or progressionof disease.Thoracic
radiography can be frustrating, however, in that the technical
aspectsof obtaining high-quality radiographs are demanding, and
appropriate patient positioning is critical. Also, the radiographic
changesmay be nonspecific. Evaluation of the pulmonary paren-
chyma can be frustrating becauseof difficulties in discerning nor-
mal from abnormal and in discriminating between the various
abnormal lung patterns. With experience and an organized ap-
proach to interpretation, al1 of these challengescan be overcome,
however.The purpose of this chapter is to present a procedural
overview for obtaining high-quality radiographs and for interpre-
ting images accurately.A review of the normal anatomy and perti-
nent physiology is presented; however, the reader is challenged to
think in terms of radiographic-pathologiccorrelation.Understand-
ing why certain roentgen abnormalities appear the way they do
enables more accurate interpretation of radiographs. Correlative
imaging modalities for further evaluation of thoracic diseaseare
also discussed.Important stepsfor reviewing thoracic radiographs
are presented,which should enable the reader to develop a system-
atic approach or paradigm for interpretation. This chapter does
not review roentgen abnormalities for all of the various diseasesof
the thorax; other chapters in this book fi1l that need. The goals
of this chapter are to acquaint the reader with normal thoracic
radiographicanatomy and possiblevariants seen,and to provide a
basisfor interpreting abnormal radiographs.
Technique and positioning
Routine thoracic radiographicexaminationconsistsof a minimum
of two radiographs that are obtained orthogonal to each other.
Standardradiographicviews of the thorax include the right lateral,
ventrodorsal(VD), and dorsoventral(DV) views.When
left 1atera1,
. Donald E. Thrall
a right versus a left lateral radiograph is described,the terminology
refersto the recumbentposition ofthe patient during radiography.
In actuality, the correct term for a "right" lateral radiograph is left-
right lateral, but in practice, lateral views are tlpically referred to
by the recumbencyof the patient. On the other hand, for VD and
DV radiographs,the name does describethe actual point of en-
trance to the point of exit of the x-ray beam, and not the recum-
bency of the patient. For example, a VD radiograph is made with
the patient in dorsal recumbency, and the point of entrance to exit
of the primary x-ray beam is ventral to dorsal.
Dependingon personalpreference,one lateral (right or left) view
and its orthogonal counterpart (DV or VD) should be obtained for
initial radiographic evaluation.aThoracic radiographs should be
made using a high-kilovolt peak (kvp) and low-milliampere-
second (mAs) technique, which maximizes the latitude of contrast
(long-scalecontrast). The highest mA and the fastesttime should
be used to minimize respiratory motion artifact. Radiographs
should be obtained on peak inspiration.
In technically adequate radiographs, coverageof the entire tho-
rax, centered at the level of the cardiac silhouette, should be
evident. The thoracic inlet to the caudalmost extent of the caudo-
dorsal lung field should thereby be included in the field ofview. A
14" x 17" cassettemay not allow inclusion of the entire thorax of
a giant-breed dog, and four images may be needed to obtain
complete coverage.These would include lateral and VD (or DV)
views of the cranial part of the thorax, and lateral and VD (or
DV) views of the caudal part of the thorax. On the lateral radio-
graph, the legs should be pulled forward so that the soft tissuesof
the brachium are not superimposedover the cranial thorax. It
should be possible to evaiuate ihe caudodorsal lung field on the
lateral view and the peripheral lung field on the VD/DV view
without the aid of a hot light. Overexposuregives the false impres-
sion of a pneumothoraxor preventssubtlelung abnormalitiesfrom
Demgseen.
Making thoracic radiographs on peak inspiration maximizes
lung contrast.5In panting dogs, timing the exposure relative to
respiration may be difficult. Holding the mouth shut for several
seconds,bringing the anode to full speed rotation, and then
allowing the dog to take a deep inspiration may allow timing
of the exposurewith inspiration. In a radiograph made at peak
inspiration, the caudodorsalaspectof the lung is caudal to T1l,
resulting in increasedradiolucencyand size of the accessorvlung
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
radiographs6
lnspiration
The diaphragm moves caudally.
There is an increaseddistancebetweenthe cardiacsilhouette
and th e dia ph rag m .
T he lun g lob es a pp ea rt o be "lar ger " and m or e "inf lat e d " ( e . 9 . ,
on the lateralview. the lungs extend to the sternum).
The lungs appear more "radiolucent."(However,pulmonary
marking sare still seen. )
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 .
T he lun g lo be s se em "s m aller " and les s "inf lat ed. "
The lungs appear more radiopaque(increasedsoft-tissue
opacity).This may cause an artifactualappearanceof an
unstructuredinterstitialpattern.
From Silverman S, Suter PF: lnfluence of inspiration and expiration on
canine thoracic radiographs. J Am Vet Med Assoc 166:502,1975.
lobe, as well as separation of the cardiac silhouette from the
diaphragm. The cranial margin of the left cranial lung lobe should
extend to the level of the first rib (Table 25-l). On the VD/DV
radiograph, indicators of inspiration include increased thoracic
cavity width and thoracic cavity length; the diaphragmatic cupola
(dome) is caudal to the mid-T8, and the caudolateral aspectof the
caudaliung lobes is caudalto T10.
The effect of positioning on thoracic radiographic appearance
must be understood.s In right lateral radiographs, the cardiac
silhouette is tlpically more oval or egg-shaped (Fig. 25-1). The
diaphragmatic crura are usuaily parallel to each other, with the
right crus being more cranial than the left. The right diaphragmatic
crus can usualiy be identified by tracing the dorsal border of the
caudal vena cava to the point at which it becomes confluent with
the right diaphragmatic crus at the caval hiatus. Air within the
fundus of the stomach may be visible behind the left diaphragmatic
crus. Overlap between the right and left cranial lobe pulmonary
vesselsis frequent in right lateral radiographs. This may make
assessmentof the relative size of the artery and vein difficult in
this view.
In the left lateral radiograph, the heart often appearsmore round
and the left diaphragmatic crus is usually more cranial than the
right. The right and left crura typically diverge away from each
other as one traces the diaphragm from a ventral to a dorsal
Figurc 25-1. Comparisonof a r;ghtand left lateralthoracicradiographfrom an adult dog (Goldenretriever).On the right laterall/A/,the diaphragmatic
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.
position. The caudal vena cava can be traced to silhouette with the
right crus, usually at a point caudal to the left crus. Food or air
within the fundic portion of the stomach can be identified caudal
to the left crus. The apex of the cardiac silhouette tends to become
displaced slightly dorsally from the sternum, giving a circular
appearanceto the overall cardiac shape. This should not be mis-
taken as a sign of right ventricular enlargement,wherein the cardiac
apex can rotate dorsally from the sternum, or of pneumothorax,
in which the cardiac silhouette is elevated away from the sternum.
Typically, distinguishing between right versus left cranial lobe pul-
monary vesselsis easier in a left lateral radiograph, and relative
vesselsize is easier to evaluate.
On a VD radiograph, the right and left diaphragmatic crura
.
have a convex appearance(thoracic surface) and are superimposed
over the larger convex cupola ofthe diaphragm. The cardiac silhou-
ette tends to be more elongated than in a DV radiograph. Changes
in the descendingaorta and great vesselsare more conspicuous on
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
its upright position (Fig. 25-2). There is better visualization of the
caudal lobar pulmonary vesselsbecausethey are magnified and not
silhouetting with the collapsed dependent lung, and they are more
perpendicular to the primary x-ray beam (see Fig. 25-Z). The
accessorylobe region is less aerated in DV radiographs becauseof
cranial displacement of the midportion of the diaphragm. Differ-
ences between right versus left lateral views and VD versus DV
vrews are more pronounced in medium-sized and large dogs than
in small dogs and cats.
Other radiographic views of the thorax that can be helpful
include oblique radiographs to evaluate rib and pleural abnormali-
ties. Radiographs made using a horizontally directed x-ray beam
with the patient in lateral recumbency or held in a standing
position can take advantageof gravity to move pleural fluid awa|
from areas of interest, such as possible lung masses. Using a
horizontal x-ray beam requires an adjustable x-ray tube head. A
common application of horizontal beam radiography is evaluation
of cats with severepleural effusion to determine whether a cranial
mediastinal mass is also present.
One very important effect of recumbency is the difference in
conspicuityof a lung lesion (nodule, mass,or infiltrate), depending
on whether the lesion is in the dependent or nondependent hemi-
thorax (Fig. 25-3).In the dependenthemithorax, t[e lung rapidly
becomes less aerated; thus its radiographic opacity increases.The
cruraare
 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-
ette with any lung lesion that is of soft-tissue opacity. Large lesions
in the dependent hemithorax may be completely invisible radio-
graphically. When the opposite view is obtained, the previously
dependent lung quickly becomes aerated, providing contrast for
the lesion and allowing it to be visualized.
I Anatomy, physiology, and
interpretation paradigm
overview
The thorax can be subdivided into four basic anatomic regions: (1)
the extrathoracic region, (2) the pleural space,(3) the pulmonary
parenchyma, and (4) the mediastinum (including the heart and
great vessels).Evaluation of each of these four areas provides the
basis for interpreting thoracic radiographs as expected structures
and opacities tlpi!' each region. It is important to memorize basic
anatomic boundaries and borders of each region, and to have
a basic understanding of the physiology of structures within a
given region.
The normal thoracic
radiograph-interpretation paradigm
Recognition of radiographic abnormalities is based on a thorough
understanding of normal radiographic appearance.Each structure
has a characteristic size, shape, opacity, margin, contour, number,
and location. This interpretation paradigm overview moves in a
systematic fashion from the extrathoracic region to the intratho-
racic regions. For the most part, thoracic diseasesinvoive only one
of the three intrathoracic regions noted previously. When two or
more of these regions are involved, a basis for understanding
pathophysiologic mechanismsis important. For example, dogs with
right-sided heart failure (e.g., passive congestion and baclaryard
failure) have pleural effusion and ascites.These areas (i.e., pleural
and peritoneal cavities) are secondarily involved. Therefore, two of
the anatomic regions are involved even though a single diseaseis
responsible for the radiographic abnormalities. An understanding
of how these two regions are connected is important based on the
underlying pathophysiology.
\A/hen interpreting thoracic radiographs, it is important to keep
severalkey factors in mind. The first is that the thoracic radiograph
is a 1/120th or 1/60th snapshot of the patient's thorax and the
stage of disease. The disease may be more advanced than the
radiographic abnormalities suggest,or changescharacteristicof the
disease may not yet be present. In other words, radiographic
changestypically lag behind the stage of the disease;this is true
for all radiographic examinations, not just those in the thorax. The
secondfact to consider is that the radiographic changesare second-
ary to alterations in normal anatomy. These anatomic alterations
may be a direct result of the disease(e.g., true anatomic abnormal-
ity), or they may be a secondary change (e.g., as that described for
right-sided heart failure). In either instance, an understanding of
normal anatomy, the anticipated radiographic anatomy, and possi-
ble radiographic abnormalities based on the underlying pathophys-
iology is imperative. Finally, during image interpretation, the focus
is often on changesin anatomy; however, these anatomic changes
may not be related to the patient's clinical signs or disease.For
example, increased interstitial lung opacity in a patient who has
lived in an urban environment may be completely unrelated to the
patient's cough. However, the radiographs must be evaluated for
abnormalities that may be associatedwith the cough.
Extrathoracic region
The extrathoracic region includes the thoracic skeleton and the
soft tissues of the thoracic wall and diaphragm. These boundaries
include the sternum ventrally, the vertebral bodies and ribs dorsally,
the ribs, the intercostal soft tissues, the subcutaneous structures
and forelimbs laterally, and the diaphragm caudally. The sternum
consistsof eight sternebrae.The first, which is elongated compared
with the other sternebrae, is the manubrium. The last sternebral
segment is the xiphoid process,which extends caudally to a level
ventral to the falciform fat. The intersternebral sDacesare fibrocar-
tilaginous joints similar to the intervertebral disc spaces of the
vertebral column. Costal cartilages from the first eight ribs insert
at the intersternebral disc space. The remaining costal cartilages
insert near the xiphoid process.Degenerativechangesof the sterne-
brae and intersternebral disc spacesare common. New bone, simi-
lar in appearanceto the osteophytesthat form secondary to spon-
dylosis deformans, and collapse of intersternebral disc space with
end-plate sclerosiscan be seen.These changesare characteristic of
older patients. Costal cartilagesmay mineralize early in life in both
dogs and cats. The costochondral junction between the body of
the rib and the costal cartilage can undergo extensivedegenerative
change with heterogeneous amorphous mineralization patterns.
These degenerativechangesshould not be confused with intrapul-
monary masses,pleural lesions, or aggressiverib lesions (seeChap-
ter 28).
The cranial aspectof the thorax is bounded by soft-tissue struc-
tures within the ventral neck at the thoracic inlet. The shoulder
joints and scapula should be evaluated for degenerativechanges.
Changes in bone opacity within the humerus and scapula should
be noted. Dorsally, the vertebral bodies should be evaluated along
with the scapulafor any changein the expectednormal appearance
of these structures.
The diaphragm should be assessedfor normal lung diaphragm
(air-soft tissue) interface and positioning. The crura and dome are
evaluated for changesin contour or position relative to each other.
Tracing each ofthe ribs should be a priority on the VD or DV and
lateral radiographs to ensure the absenceof rib pathology. Based
on the lateral radiograph, soft tissuesventral to the sternum, soft-
tissue massesor fatty masses,or nipples may result in superim-
posed lung opacity. Nipple shadows typically are bilateral and are
located within one intercostal spaceof each other in opposite lung
fields on the VD or DV radiograph.
Pleural space
The pleural space is the next region to be evaluated. The normal
pleura is composed of two layers-parietal and visceral. The pari-
etal pleura lines the thoracic cavity and is fused with the thoracic
wall (intercostal spaces and ribs) and diaphragm. Medially, the
parietal pleura reflects dorsally at the level of the sternum; it also
reflects ventrally at the level of the vertebrae to form the mediasti-
nal pleura. At the pulmonary hilum, the parietal pleura also reflects
onto the outer pulmonary surface and becomesthe visceral pleura.
Normally, the pleural space contains a very small amount of fluid
that is not visualized on thoracic radiographs. Production of pleu-
ral fluid is continuous; however, becausethe fluid is also absorbed,
a net accumulation of fluid does not occur. In older patients,
pleural thickening may be present, particularly between the right
middle and right caudal lung lobes and is seen best on a left
lateral radiograph; however, this is not significant unless other
radiographic abnormalities are present. Knowledge of the localiza-
tion of the normal pulmonary fissures is important as these are
sites of fluid or air accumulation and also represent boundaries
and borders for lung pathology. These boundaries are reviewed ifi
the next section and also in Chapter 31.
Pulmonary palenchyma
The pulmonary parenchyma consists of three structures that are
normally visualized on routine thoracic radiographs: (1) the walls
of the airways to the level of the primary and secondary divisions
of the bronchi, (2) the pulmonary arteries and pulmonary veins,
and (3) the lung interstitium, or the connective tissue framework
of the lung.
Airway walls. The airway walls appear as thin parallel tissue

Iines that taper and branch into the periphery. When a bronchus
is viewed end-on, it will have a circular appearance. As a dog ages,
the tracheal and bronchial walls and cartilage rings may undergo
dystrophic mineralization and be more conspicuous.On a right
Iateral radiograph, the first radiolucent oval region superimposed
on the trachea at the heart base area is the bronchus to the right
cranial lung lobe. If the ventral margin of the trachea is traced
further caudal, the opening into the left cranial lung lobe can be
seen.It travels approximately 1 cm in a medium-sized to large dog
and bifurcates into the bronchi to the cranial and caudal segments
of the left cranial lung lobe. At the carina, the trachea terminates
into the right and 1eftprincipal bronchi. The right middle bronchus
originates at this termination from the right principal bronchus,
and is best seen on a left lateral radiograph. The accessorylung
lobe bronchus originatesjust caudalto the cardiacsilhouettefrom
the right principal bronchus.
Pulmonary arteries and veins. On lateral radiographs, pulmo-
nary arteries are located dorsal to their corresponding airways,
which, in turn, are dorsal to their correspondingpulmonary veins.
On the VD or DV radiograph, the pulmonary artery to a given
lung lobe is lateralto the bronchusto that lobe and the pulmonary
vein is medial. These relationships are extremely important. On an
adequatelyexposednormal radiograph,one should be able to trace
the branching pulmonary vesselsto the periphery of the lung field.
These pulmonary vesselshave their largest overall diameter closest
to the heart and taper and branch toward the periphery. The
branching is linear and is not curved, irregular, or blunted in the
normal dog and cat. The vesselsare of soft-tissue opacity. In
general, the size of any pulmonary artery within the pulmonary
parenchymashould match the sizeof the correspondingpulmonary
vein at any given level. Although the relative size of pulmonary
arteries and veins is usually sufficient to assesswhether either vessel
is abnormal, absolute size can be quantified. For example, the
pulmonary artery and vein supplying the right cranial lung lobe
should not have a diameter greater than the proximal aspectof the
4th rib. Also, the diameter of the caudal lobe pulmonary artery
and vein should equal the thicknessof the 9th rib at the point at
Figure 254. ,4, Close-up of a dorso-
v e n t r a l r a d i o g r a p ho f th e ca u d a lth o r a x
frorr a dog witl- d patert dLctus a'ler:o
s u s .T h e s h u n t r e s u l tsin p u m o n a r yo ve r -
c i r c u l a t i oa
n n d e n l a r ge m e not f th e ca u d a l
lo b a ra r t e r i e sa n d v e i ns.T h e a r te r ie sa n d
v e i n sa r e s i m i l a ri n s l ze ,a n d e a chfo r m s a
s u m m a t i o ns h a d o ww ith th e 1 Othr lb th a t
is t h e s h a p eo f a h o r lzo n tarle cta n ge . In
/ , al th e n rr'l i ^e o ' h c a - pr v ano t b l- ave
b ee n t'a ce d , a ^ d rh e l 'or zonr al r ec a- gular
s umma ti o n re g i o n i s o bv ous. lf the vesse
a r d ri b a re th e sa re s ze, tl- e sJnm atior
r e g i o n w i I b e sq u a re , and if the vessel is
s na l e r rl -a r ro ma , r he s- 1- ]Talior r e :,,:'2,:rri':'l::l:
g i o n wi I a g a i n b e re ctangular ,but the ong
a xi s o f th e re cta n g l e w I be or iented ver tr - ,,,i]&,.,,,'ll:
cary.
Interpretati on
P aradi gms
for the S mal lA ni ma lThor ax 3ll
which the vesselscross the rib. In other words, the summation
shadowof the intersectingvesseland the 9th rib should be a square.
If the vesselis enlarged, the summation shadow is rectangular with
the largestdimension being horizontal; if the vesselis small, the
summation shadow is rectangular with the largest dimension being
vertical (Fig. 25-a). It is important to realize that relationships,
such as the relative size of the caudal lobe vesselsand the 9th rib,
are only guidelinesand are not accurate 100% of the time (see
Chapter 33).
Lung interstitium. The interstitium is the non-air-containins
part of the lung in which the pulmonary vessels, bronchi, Iymphat-
ics, and pulmonary parenchyma/connectivetissue (i.e., alveolar
septum, interlobar septum) are located. The interstitium is the
sourceof the lacy soft-tissueopacity visible on closeinspectionof
normal lung radiographs.There are varying degreesof pulmonary
connectivetissuebetweenspecies.As a result, the lungs of animals
with more connectivetissuenormally appearmore opaque (white).
In order of increasingamounts of pulmonary connectivetissueare
dogs and cats,then the.horses,cattle,pigs. and humans.
Mediastinum
The mediastinum is the spacebetween the right and left pleural
sacs.In the dog and cat, the mediastinal pleura is incomplete,
meaning that nonviscidpleural effusions(e.g.,transudates)tend to
be bilateral. Exudative effusions (e.g., pyothorax, chylothorax, or
hemothorax) tend to be unilateral owing to the plugging of the
fenestrated,incompletemediastinalpleura.
The mediastinum, when viewed dorsally, is characterized by
reflections wherein certain structures push the mediastinum away
from its normal midline iocation. These mediastinal reflections
develop as the lungs grow and cross the ventral aspect of the
midline. Three different reflectionsare described(Fig. 25-5). The
cranioventral mediastinal reflection forms when the lingula portion
of the left cranial lung lobe extends acrossthe midline from left to
right at the thoracic inlet. The ventral portion of the right cranial
lung lobe aiso extendsacrossmidline in a right to left direction
just cranial to the cardiac silhouette.ThesetwL ventral extensions
.lrrrt!rrrrr,rrr:lrrri
rl!rlr,,.,lllell,iil3
rrr3r,,19|l$
;|1,''::iiirrr..:iilBrl
riirle]tr:iit$lllllll
d - e- I
' b : q :.
, e:&l
:- B q
li"riall:111@lll:
rrrrelllr:llt
:,tirlll,:ll
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itlitrQlul:l
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3 I2 NE CKA ND T H O R AX -C OMP AN IO AN
N IM ALS
Figure 2S-5. Reformatteddorsal /A/ and transverse1Blcomputedtomographyimagesof a caninethorax illustrattngth-ocranioventral
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-
tion (Fig. 25-5). The thymus and sternal lymph node are two
soft tissue structures found in this reflection' The caudoventral
mediastinal reflection is a result of the growth of the accessory
lung lobe as it develops and pushes the mediastinum from the
right to the left. The caval mediastinal reflection, or plica vena cava,
is not visible as a distinct structure,but representsthe mediastinum
wrapped around the caudal vena cava in the right hemithora-x.
Theie reflections are important anatomic landmarks' For example,
the caudoventral mediastinal reflection forms the left lateral extent
of the accessorylung lobe on the VD or DV radiograph. Within
the middle mediastinum, the cardiac silhouette also pushes the
mediastinum apart ventrally. The right convexity of the cardiac
silhouette displaces the right lung lobe in a rightward direction,
and the 1eft convexity of the cardiac siihouette displacesthe ventral
portion of the left lung lobe in a leftward direction' Dorsally, the
mediastinum is a midline structure.
The mediastinum can be divided into cranial, middle, and caudal
parts, with each having imaginary ventral and dorsal compart-
ments. Surrounding the trachea on the lateral radiograph is a
confluence of soft-tissuestructures that cannot be distinguished
becauseof silhouetting with each other. These structures include
vessels,the esophagus,lymph nodes, and nerves' See Table 30-l
for a complete listing of mediastinal organs.
In the ventral aspectof the cranial mediastinum, the left craniai
lung lobe lingula and the cranial mediastinal reflection are seen.
The sternal lymph node is not seen unless enlarged.In a young
animal, the thymus can occasionally be identified in a lateral
radiograph between the right cranial lung lobe and the cardiac
silhouette. More commonly, the thymus can be seen on the VD or
DV radiograph extending in the cranioventral mediastinum reflec-
tion between the left cranial and right cranial lung lobes. The
thymus createsan opacity that is usually curved and triangular in
shape and extends from the midline in a convex fashion, following
the medial border of the left cranial lung lobe into the left hemitho-
rax. This has been called the "sail sign" (Fig. 25-6). On VD and
DV radiographs, the trachea is normally located slightly to the
right of midline. The right margin of the cranial mediastinum on
the VD or DV radiograph is usually formed by the lateral margin
of the cranial vena cava.
i,.;.-i
sl
mediastlnalref -octlon.
Dorsally in the middle mediastinum, the trachea terminates at
the carina into the principal bronchi. The descendingaorta is
visualizedbecauseof its position along the medial border of the
1eft and right caudal lung lobes. On the VD/DV radiograph, the
aortic arch extends toward the left of midline beyond the vertebral
bodies. The descendingaorta then convergesin a straight line
toward the vertebral bodies at the centrally located aortic hiatus of
the diaphragm. The esophagusis usually not visible on the lateral
or VD/DV radiograph in this portion of the mediastinum. The
dorsal portion of the middle mediastinum also contains the tra-
cheobronchiallymph nodes,phrenic nerve,vagosympathetictrunk,
and so forth. These structuresare not visualizedon normal tho-
racic radiographs(seeChapter 30).
Lungs
There are two lungs, each of which occupies approximately 50o/oof
the thoracic cavity. The right lung is divided into right cranial,
right middle, right caudal, and accessorylobes. The left lung is
divided into left cranial (further subdivided into cranial and caudal
parts) and left caudal lobes. These lobes occupy specificareasof
the thoracic cavity. Even though interlobar fissuresare not identi-
fiable on routine thoracic radiographs,the expectedanatomicloca-
tion of thesefissuresmust be understood.
On the VD or DV radiograph,interlobar fissurescurve from the
thoracic wall in a cranial and medial direction toward the pulmo-
nary hilum (trachea), with the convex side of the curve located
cranlalty ttrgr. zJ-/ t,
. The fissure between the right cranial and right middle lobes is
located at the 1eve1of the 4th to 5th intercostal space
. The fissure between the right middle and right caudal lobes is
located at the level of the 6th to 7th intercostal space
. The fissurebetween the cranial and caudai parts ofthe left cranial
lobe is located at the level of the 4th intercostal space
. The fissure between the 1eftcranial and Ieft caudal lobes is located
at the 1eve1of the 6th to 7th intercostal space
It should be noted that fluid typically would not extend along
an entire fissure.
. Dorsal to the heart, the right cranial lobe contacts the right
-*-H :J

Figure 25-6' Fight lateraland ventrodorsal(VD) radiographsof a 1O-month-old
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
caudal lobe, and the cranial part of the left cranial lobe contacts
the left caudal lobe. Thus, there is opportunity to see an interlo-
bar fissure on lateral radiographs extending in a dorsal direction
from the region of the tracheal bifurcation, if there is thickening
or fluid accumulation within this fissure.
Pattern lecognition for assessment
One method for assessingradiographic alterationsof the lung is
called pattern recognition.Tr0Pattern recognition is based on the
theory that diseasesaffecting the alveoli have a different appearance
than those primarily affecting the airways (bronchi). Also, these
appearancesare both different from that of diseasethat primarily
affects the interstitium or pulmonary vessels. Thus, diagnostic
considerationscan be restricted to certain groups of diseasesby
careful identification of the compartment of the lung that is radio-
graphically abnormal. Pattern recognition is a convenient method
by which confidence can be gained in assessingradiographic abnor-
malities of the lung. It is important to reaiize that the specific lung
lobe involved, the distribution of the abnormality in the lung, and
the signalment and history are also important in refining the list
of differential diagnoses.The four basic pulmonary patterns are:
(1) alveolar,(2) interstitial, (3) vascular,and (4) bronchial (Table
25-2). SeeChapter 34 for a more detailed discussionof lung pat-
terns.
Alveolar pattern. The hallmark of the aiveolar pattern is the
air bronchogram (Table 25-3 and Fig.25-8).1There are two gen-
eral causesof an air bronchogram. An air bronchogram may be
createdby air in the bronchial lumen when surrounding alveoli
Tahle 25-2. The different forms of pulmonary patterns
in sma ll an imals
Alv eolar
InterstitiaI
Structured
Unstructured
Br onc hial
Vascular
l nterpretati on
P aradi gms
for the S mal lA ni ma lThor ax 313
dog. On the ateral radiograph,there is an increasedsoft-tissueopacttylust
Theseopaci ti esare typi calfor the normalthvmusor a thvmi cremnant.
become filled with fluid and cells. The fluid and cells replace the
air within the alveoli and the lung assumesa soft-tissue opacity.
Radiographicaliy, this is considered consolidation. Another cause
of air bronchogram formation is collapse of the alveolar air space.
This loss of air results in a soft-tissue opacity of the lung at
that site. Radiographically, this is considered atelectasis.rlIn either
instance, the bronchial lumen becomes visible radiographically
becauseofthe contrastprovided by the increasedsoft-tissueopacity
that surrounds it. It may be difficult to determine if an alveolar
pattern is the result of consolidationor atelectasis. There are some
radiographic findings that may be used to distinguish between the
two causes.An atelectic iung lobe is decreasedin size. As a result,
there is often a shift of mediastinal structures, such as the cardiac
silhouette, toward the collapsed1ung.Atelectic lung lobes are com-
monly associatedwith pneumothorax or pleural effusion. Alterna-
tively, consolidated lung lobes typically retain their shape and size
so there is no mediastinal shift. However, there are gradations of
change and these findings are not absolute. One cannbt always tell
with absolute certainty if the alveolar pattern is the result of
consolidation or atelectasis,but it is important to try to decide
becausethis decision impacts the differeniial diagnosis 1ist.
In the cat, the right middle lung lobe undergoesatelectasismore
-
frequently than other lung lobes.rr This fact ii due to a reiatively
larger ratio of pleural space to area of lung volume, a decreasein
the effectivenessof the collateral ventilation in this lung lobe, and
a decreasein compliance in this lobe, which worsens when there is
Table 25-3. Radiographic signs of an alveolar pattern
L a c ko f v i s u a l i z a t i o no f t h e p u l m o n a r yv a s c u l a t u r ei n th e r e g i o n
of the alveolarpattern (due to silhouetteeffect)
Increasedsoft-tissueopacity-may be mild, moderare,or
severe.May be patchyto homogeneous
May have summation effect if alveolarpattern is superimposed
over the cardiacsilhouette
M a y h a v e a l o b a r s i g n i f t h e d i s e a s eo c c u r sa l o n g th e p e r i p h e r y
of a lung lobe
T y p i c a l l yh a s a n a i r b r o n c h o g r a m
3 I4 NE CKA ND T H OR AX -C OMP AN IOAN
N IM A LS

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

Figure 25-8. C ose-upof the ventrallungfrom a left lateralradrograph
o f a d o g w i t h a s p i r a tio n p n e u m o n iaNo
. te th e a lve o la pr a tte rnsuperm
p o s e do v e rt h e c a r d i a ca p e xr e g io nAir
. b r o n ch o g r a masr e visibe. B ased
o n l o c a t i o nt,h i s a l v e o la rd ise a seis in th e r ig h t m d d le lu n g (l eft l ung
d l s e a s ew o u d n o t b e se e nb e ca u seth e d o g is r n le ft la te r ar e cumbency).
T h e r el s a l o b a rs i g nbe twe e nth e r lg h tm d d lea n dth e ca u d a lung obes.
pulmonary disease.Right middle lung lobe collapseis best identi-
fied on the VD or 1eftlateral radiograph. The radiographic findings
include a decreasein the size of the right middle lung lobe,
development of a triangular soft-tissue opacity in the right middle
lung lobe in the VD/DV view and a mediastinalshift to the right
if the condition is acute. One generallydoes not see air broncho-
grams in chronic stages of fibrosis. The mediastinal shift may
resolveif the atelectasisis chronic as the surrounding lung lobes
hyperinflate and move the mediastinal structures to a more nor-
mal position.
With an alveolar pattern, the pulmonary vesselsand outer mar-
gins of the bronchial wa1lsare not seen becausethey silhouette
with the material in the alveoli. Air bronchograms are easy to see
if there is severealveolar diseasebut they may be difficult to see if
the alveolar diseaseis patchy or mild. Importantly, an air broncho-
gram is not alwayspresent with alveolar diseasebecausethe airways
may be filled with fluid and cells, resulting in total consolidation
of the luns lobe.
The distiibution of an alveolar pattern influences the differential
considerations.Therefore, the radiographic anatomy of the lung
Iobes must be known. For example, a cranioventral or ventral
alveolarpattern is a common consequenceof bronchopneumonia
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
Examplesof a structured pattern are pulmonary nodules (<3 cm
in size) and masses(>3 cm in size). An unstructured interstitial
pattern is a collection of fluid, cells,or fibrosiswithin the connec-
Table 254. Radiographic criteria for structured
interstitial pulmonary pattern
SZe; Small (few mm)-large (cm)
Sha pe : Rou nd an d well- c ir c um s c r ibed
Number: One to many
Opacity: Cavitary(gas opacity/lucent)and/or noncavitary(soft
tissue,fat, and mineral opacity)
Location: In the interstitialspace.May be locatedin any part of
th e lu ng lob e (e . 9. ,dor s al,v ent r al)
Margination:Variesfrom well definedto ill defined {if
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
a s ed ema or h em or r hage)
Interpretati on
P aradi gms
for the S mal lA ni ma lThor ax 315
tive tissue framework of the lung, between the alveoli and around
the vesselsand airways. Interstitial pulmonary pattern must be
categorizedas structured or unstructured becausethis classification
influences the differential diasnosis list.
The structured interstitial pintt.r,l can be further subdivided into
cavitary and noncavitary types (Table 25-a). A cavitary nodule
contains gas,which can occupy the entire nodule or only a portion
ofthe nodule (Fig. 25-9)., A noncavitarynodule or massdoesnot
contain gas, but it may comprise soft tissue, fat, mineral, or a
combination of theseopacities(Fig. 25-10). For a singlesoft-tissue
pulmonary nodule to be visualized on thoracic radiographs,its
diameter must be 5 to 6 mm. Smaller soft-tissuenodules do not
absorb sufficient photons to become apparent radiographically.
Mineralization within the nodule renders visible nodules smaller
than 5 to 6 mm in diameter.
Pulmonary vesselsprojectedend on may be confusedwith non-
cavitary pulmonary nodules. Obviously, it is important to attempt
to distinguishbetween an end-on vesseland a pulmonary nodule
becausethis distinction determinesif additional diaenostictestsare
needed (Table 25-5). Superficial thoracic wall iasses, such as
ectoparasitesor thelia, may be confusedwith noncavitarypuimo-
nary nodules (seeChapter 5).
Table 25-5. Noncavitary pulmonary nodules versus
end-on vessels
End-onvessels
Closelyassociatedwith longitudinalvessels
Often follow an organized"pattern"
Very opaque soft-tissueopacity (resultof viewing a "length" of
vessel)
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
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
We l l - d e f i n e dm a r g i n s
Pulmonarynodule
Not necessarilyassociatedwith a vessel
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
without regardfor vesselorientationor position)
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
soft-tissueopacity)
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
(2 to 4 mm in size) and well defined, and that can be confused
with soft-tissue pulmonary nodules, are subpleural and pulmonary
osteomas.r0 These areasof osseousmetaplasiaare found just be-
neath the viscerai pleura along the lung surfacewithin the intersti-
tium. They appearas well-defined(mineralized)focal noduleswith
a dependent predilection for a ventral position, but they can be
found throughout the lung fields. Additionally, Sheltie and Collie
breeds are especially prone to this change, which appears to be
age-relatedand more common in older dogs.
An unstructured interstitial pattern may result from an increase
in fluid and cells, or from fibrosis, in the interstitial space (Fig.
25-11). The increase in soft-tissue opacity results in decreased
visualization of the margins of pulmonary vesselsbut may con-
versely result in enhancedvisualization of airways (Table 25-6).
Figure 25-9. Close-up of the dorsocaudal
iungfrom a rightlateral
radiograph
of a dogwitha pulmonary bulla.
Thebullain thecaudallobe
hasthin,smoothmargins andcontains gas.Thisappearance is more
consistent
with a traumaticor congenital
bula.Cavitaryabscesses or
tumorsoftenhavethicker andmoreirreoular walls.
There are technical issues that must be understood so that a
false-positive diagnosis of an unstructured interstitial pulmonary
pattern can be prevented. The phase of respiration is very im-
portant. Optimally, thoracic radiographs are made on full inspira-
tion. This allows the lungs to be well aerated, providing optimal
contrast between intrathoracic structures. When radiographs are
made on expiration, the interstitium appears artifactually opaque,
and accurate evaluation of the lungs is impossible (Frg. 25-I2).lf
the radiograph is underexposed (too light), the interstitium also
appears artifactually opaque. The opposite happens when the ra-
diograph is overexposed(too dark).
Vascular pattern. Radiographically detectablechangesin vessel
sizeequateto a vascularpattern.8Correspondingpulmonary arter-
ies and veins should be approximately the same size. If there is
asymmetry in size between vessels, or if they are larger than
Figure 25-1O. Close-upof the craniallung from a left lateralradio-
graphof a dog wlth metastaticlung diseaseof unknownetiology.Two
soft ti ssuemassesare vi si bl e.
 l nterpretati on
P aradi gms
for the S mal lA ni malThor ax 317

Figurc 25-11. Cose-up of the caudodorsalung from a left lateral

radiographof a dog with an unstructuredinterstitialpatternof unknown
etiology.Note that there is an overallincreasein soft-tissueopacity,
w i t h d e c r e a s evdi s u allza tioonf o u lm o n a rve v sse lsa n d in cr e a sed vi sual -
iz a t i o no f t h e a i r w a ys.Co m p a r eth is fig u r ewith F ig u r e2 5 - 1 2 8.

llr,.,il
ll$ll,

: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
Table 25-6. Radiographic criteria for unstructured
pulmonary pattern
Increasedsoft-tissueopacity (sometimesdescribedas a "hazy
or lacy" appearance)
"Fuzzy"vessel margins (but persistentvisualizationof vessels)
Possibleenhancementof visualizationof bronchi if pattern is
centerednear the airways
specified in the radiographic guideline, then a vascular pattern is
present. A smaller than normal appearanceof vessels(as seenwith
hlpovolemia) also constitutes a vascular pattern (Table 25-7).
Pulmonary vesseisnormally have a soft-tissue opacity; however,
mineralization of vesselscan occur secondaryto endothelial pathol-
ogy due to uremia, heartworm disease,thromboembolism, or hy-
pothyroidism.
The tortuosity, blunting, or pruning of pulmonary arteries de-
scribed in patients with canine heartworm disease constitutes a
change in vascular shape that would also be classifiedas a vascular
pattern (Fig. 25-13).
Bronchial paftern. When airways are visually enhanced,a bron-
chial pattern is present(Fig. 25-14).8This can occur when there is
thickening or mineralization of the bronchial wall, or when there
is an increasein soft tissue (e.g., a peribronchial infiltrate) adjacent
to the wall. An apparent increasein airway size and lumen diame-
ter, as well as loss of normal tapering (bronchiectasis),also consti-
tutes a bronchial pattern. It is important to try to determine which
of these listed factors may contribute to the bronchial pattern
because this decision will assist in determinins the differential
diagnosis list.
Cardiac silhouette
The most conspicuous opacity in the middle mediastinum is the
cardiac silhouette, comprising the pericardium, great vessels(i.e.,
ascending aorta, aortic arch, main pulmonary artery), heart, and
blood within the heart. The cardiac silhouette occupies two thirds
of the middle mediastinum on the lateral radiograph, has an oval
appearance, and is located between the 4th and 6th intercostal
spaces.2'3't''t3 Evaluation of the cardiac silhouette can be imprecise
becausebreed variation accounts for large differencesin apparent
size. Thoracic conformation must be taken into account when
Table 25-7. Radiographic criteria for vascular pattern
SLe: Increased,decreased,asymmetry between artery and vein
Shape: Loss of normal taper (e.9.,blunted,tortuous)
Number: Apparent increaseor decrease
Opacity: Pulmonaryvascularmineralization
cardiac silhouette size is evaluated in dogs (Fig. 25-15). With a
deep, narrow chest (such as is found in Doberman pinschers), the
heart has an upright appearanceand is relatively small compared
with the overall thoracic volume. On the VD/DV view, the heart
may appear more rounded than oval becauseof the upright orien-
tation of the heart (seeChapter 32).
In a medium-sized dog with averagethoracic confirmation
(Golden retriever or mixed-breed dog), the cardiac base is inclined
in a more cranial direction, and the cranial heart margin appears
to lie along the sternum. On the VD/DV view, the cardiac silhouette
appears more oval. In small chondrodystrophoid dogs, or dogs
with a barrel-shaped thorax, the cardiac silhouette tyically appears
large on the lateral radiograph relative to the overall thoracic
volume. The cardiac base has marked cranial inclination, and the
heart may appear to occupy 600loto 70o/oof the thoracic volume.
On a VD or DV radiograph, however, the cardiac silhouette has a
more normal size relative to the thoracic volume; this illustrates
the importance of obtaining orthogonal radiographs whenever pos-
sible. In addition to breed-relatedfactors, the degreeof inspiration
can influence the radiographic appearanceofthe cardiac silhouette.
The heart
In general, the cardiac silhouette in dogs should be 3 to 3.5
times the width of an intercostal space on the lateral radiograph
(measured in the largest diameter of the cardiac silhouette). In the
cat, the maximum diameter of the cardiac silhouette (usually the
heart base) should be 2 to 3 times the width of an intercostal space.
The basilar-to-apical length ofthe cardiac silhouette is usually 600lo
of the dorsoventral height of the thoracic cavity on the lateral
radiograph. On the VD or DV radiograph, the cardiac silhouette
size should not exceed50oloof the pleura-to-pleura diameter at the
9th intercostal space.These are rules of thumb that should aid in
the initial assessmentof cardiac size.
Recently, a cardiac measurement technique, called the vertebral
Figure 25-13. Left lateralradiographof a dog with heartwormdis-
ease. N ote the numerousenl argedand tortuouspul monaryarteri es ,
particularly
the right craniallobe artery.

Figure 25-14. Close-upof the caudodorsallung from a lett lateral
ra d i o g r a pohf a c a t w i t h a b r o n ch iap a tte r n No
. teth e e n d - o na r w ays
lring shadows)throughoutthe lung.
heart score, has been describedwhereby the sum of the heart
length and width on the lateral radiograph is normalized to verte-
bral length.ta'r5This technique can provide objective criteria for
evaluationofthe heart. The vertebralheart scoreshould not reolace
subjectiveradiographic evaluation of cardiac size and shape.As
yet, improved accuracyof the vertebral heart scoreversussubjective
evaluation for assessingcardiac abnormalities has not been
proved.r6
The cardiac silhouette tends to be primariiy located in the 1eft
hemithora-xon VD or DV radiographs,much more so on DV
radiographsbecauseof cranial excursion of the diaphragm. The
l nterpretati on
P aradi gms
for the S mal lA ni malThor ax 3lg
apex points toward the ieft costodiaphragmatic angle. The shape
of the cardiac silhouette tends to be rounder on ih" l"ft lut"iul
view because of rotation of the apex dorsallv from the sternum.
The, descendingaorta and main p.,l-otruty aitery extend leftward
of the vertebralbodies on the VD/DV radiograph.
The opacity of all structures of the cardiac silhouette is that of
soft tissue; therefore, differentiation of the various chambers,
valves,blood, surfaces,and vesselscannot be made without admin-
istration of contrast medium or use of echocardiography.
In actuality, the accuracy of identification of specific cardiac
abnormalitiesin survey radiographsis very poor. Ao*.uer, .orr-
Figure 25-15. Right lateralradiographs from a normalDobermaniAl, a
Goldenretriever(B), and a poodle /C/ showing a wide variationin cardiac
srhouette si zes and shapesbased on thoraci cconformati on. S ee tex t
TOr0etai l s.
3 ,2 O NE CKA ND T H O R AX -C OMP AN IO AN
N IM ALS

tout size, and shape changesspecif,c to cardiac enlargement pat-

terns have been described. These changesare described in Chapter
32. One system that helps to familiarize students with the process
of evaluation of cardiac abnormalities is the analogy of the cardiac
silhouette as a clock face. Specific changeswithin a given region of
the clock face can be correlated with a specific chamber or great
vesselenlargement (Figs. 25-16 and 25-17). If these changes are
absent, cardiac diseasecannot be excluded solely on the basis of
survey thoracic radiographs.

Rules for radiographic interpretation

In evaluation of the heart, great vessels,pulmonary vessels,and
parenchyrna, certain rules specific to an interpretation paradigm
should be followed. These rules are basically answersto five ques-
tions related to the radiographic abnormalities that are present
(Fig. 2s-18):
. Is there any radiographic abnormality of the cardiac silhouette
(change in size, shape, opacity, location, margination, and num-
ber)? What is the expectednormal apPearanceof the heart based
on the breed of the patient?
. If cardiomegaly is present, are the changesconsistent with right-
sided enlargement, left-sided enlargement, or generalizedcardio-
megaly?
. Are there alterations of the pulmonary arteries and veins within
the peripheral lung field (e.g., undercirculated, overcirculated,
pulmonary artery larger than the vein, or pulmonary vein larger
than the corresponding artery)?
. Is there evidence of left-sided heart failure (e.g., pulmonary
edema), right-sided heart failure (e.g., pleural effi.rsion,hepato-
megaly), or both?
. Is there enlargement of the descending aorta, heart base region,
main pulmonary artery segment, or caudal vena cava?This last
question requires evaluation of a well-positioned VD/DV radio-
graph and is critical for evaluating the great vesselsfor radio-
graphic evidence of poststenotic dilation related to congenital
heart defects.
Notice that these questions integrate several general categories
I
Figure25-1 7. Theclockfaceanalogy superimposed overthecardiac silhou-
ettefromthe ventrodorsal radiograph.Notethe position of the various cardiac
chambers relativeto the clockface.lt is important to realizethat there is
superimDosition of the variouschambers andvesselswithinthe middleof the
cardiac silhouette.Enlargement in the areaof 2 to 3 o'clockreflectsenlarge-
mentof the leftauricle appendage asthe mainbodyof the leftatriumis noted
superimposed overthe middleof the leftventriclejustcaudal to the bifurcation
of the trachea intothe rightandleftcaudal mainstem bronchi. *, Themain
bodyof the leftauricle(asthe left atriumenlarges, it mayextendbeyondthe
cardiacsilhouettein the areabetween5 and 7 o'clock).The arealocated
between2 and 3 o'clockrepresents the areaof the left auricle.lf the left
auricleisenlarged, themainbodyof theleftatrium willalsobeenlarged, unless
theenlargement is secondaryto a masswithintheleftauricle (e.9., myxoma).
of abnormalities (i.e., mediastinum, great vessels,heart, pleural
space, and pulmonary parenchyma), and the reader needs to be
familiar with all potential aspectsof cardiac-related diseaseprior
to answering them. Do the answers make sense?A dog with
endocardiosis of the mitral valve and vah.ular insufficiency would
develop left-sided heart failure (i.e., pulmonary edema) but would
not be expectedto have an enlarged caudal vena cava or a ductus
diverticulum (i.e., focal enlargement of the descendingaortic arch).
Within the context of these answers,the radiographs would need
to be reevaluatedto ensure that the correct interoretation has been
made. This does not mean that multiple abnoimalities may not
be present; however, one should try to relate all radiographic
abnormalities into one diseasewithin the known context of ex-
pected anatomic and pathophysiologic changes.

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
Anatomic considerations
The pharynx, borderedby the baseofthe tongue and the retropha-
rprgeal wall, is divided into oropharynx and nasopharynx by the
soft palate, which extends to the level of the epiglottis. On high-
quaiity lateral radiographs, many laryngeal structures can be identi-
fied (Fig. 26-7).1 Laryngeal structures are diflicult to seeon ventro-
dorsalviews becauseof overlyingstructures.In lateral radiographs,
the transverse basihyoid bone is usually obvious because it is
projected on end and may be mistaken for a foreign object.
Radiographs of brachycephalic dogs, as well as those of obese
animals, are more difficult to interpret becauseof the larger
amount of soft tissue and fat (Frg. 26-2). This resultsin a lower
air-to-tissue ratio, providing less contrast as well as opacities that
are more irregular.
In very young animals (2 to 3 months of age), laryngealstruc-
tures may not be well defined because they are not sufficiently
mineralized. Mineralization in laryngeal cartilaginous structures,
including the epiglottis,is a normal changeof aging.Mineralization
may be seen in animals as young as 2 to 3 years of age and is
expected to occur earlier in large and chondrodystrophic dogs. In
one study, 96 of 99 clinically normal dogs of random breeds
and random age older than 1 year had radiographic laryngeal
mineralization.': The cricoid cartilage is usually the first laryngeal
cartilage to become mineralized.
In a routine lateral view with the head in a normal position, the
larlnx is usually ventral to the first two cervical vertebrae. It is
usually just slightly more ventral than the main portion of the
cervicaltrachea.If the radiographis made with the head extended,
the larynx is pulled slightly cranial and is closer to the spine.
Additionally, the hyoid bones are at a lesser angle to one another,
and the ventrodorsaldiameter of the pharynx may be compressed.
Figure 26-1. A norma lateral radiographof the laryngeal
region of a 6-month-oldmixed-breeddog. The soft pa ate /A/
s e p a r a t e tsh e n a s o p h a r ynfrxo m th e o r o p h a r yn x.
T h e e p igo tt s
(white arrow) extends from the arynx to the tip of the soft
palate.The cranialcornuaof the thyrod carttlage(blackarrow)
s h o u l dn o t b e m i s t a ke nfo r a fo r e io no b ie ct.No te th e e n d - on
v i e w o f t h e b a s i h y o id
bone.
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-
cult to see,and overlying skin folds are more like1y.
Dependingon the phaseand depth ofrespiration during radiog-
raphy, the tip of the epiglottis may be just dorsal or ventral to the
soft palate, or it may be on the ventral floor of the pharynx. This
variation may be seen in normal animals; however, in the presence
of swallowing disorders,radiographic and fluoroscopic examina-
tion should be performed during swallowing to determine if the
epiglottismovesnormally.
The hyoid bones are relatively well defined and easy to identifr
in the dog and cat. The key to diagnostic accuracy is simply
familiarity with the normal appearance.Hyoid bones have been
mistakenly diagnosed as foreign objects. The configuration and
relative position of the hyoid bones are rather uniform among
small animals; however, the position of the head, tongue, and
larynx during radiography causesvariation in the angles between
hyoid bones. Oblique views may causesignificantdistortion, lead-
ing to erroneous diagnosis.Few radiographic abnormalities are
evident in the hyoid bones.The most common of theseabnormali-
ties are fracturesand dislocations.
Radiographic signs of disease
Space-occupyinglesions
Masslesions,such as abscesses, polyps, neoplasms,and granulation
tissue, may be readily identified with appropriate radiographic
technique and accurate positioning, and with applied knowledge
of normal anatomy. When small, these lesions appear as variants
in the normal shape of structures, and, when large, they may
obliterate air-filled cavities. Such mass lesions may be found at any
location (Fig. 26-3). Variation in radiographic technique may be
necessaryto demonstrate such lesions, owing to the variations in
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
region. Depending on the shape,physical density, and architecture,
foreign objects lodged in the airway may be identified specifically,
or they may appearas space-occupying tissuemasses.
Space-occupying masses outside the larynx/pharynx are more
difficult to identiff becausethey are not surrounded by gas. These
lesions are identified through recognition of displacementor en-
croachment of the air-tissue interfaces. Although massesmay de-
velop at any site, enlargement of specific structures, such as a
lymph node or the thyroid gland, should be consideredas possible
causesof such radiographicabnormalities.Swellingin the pharyn-
geal/laryngealsoft tissueshas been reported secondaryto rodenti-
cide ingestion.3'a
Functional abnormalities
Functional abnormalities of the larynx are best evaluatedby direct
visual inspection. Neurogenic disorders result in mild or equivocal
radiographicsigns.sConsistentmisplacementof the epiglottis seen
on radiographsshould prompt visual examination.In the panting
dog, the epiglottislies on the ventral floor of the pharlnx.' Other-
wise, it is in a semi-erectposition, usually with the tip just dorsal
or ventral to the soft oalate.
Figure 26-2. A normal latera radiographof the laryngea
regi onof an obese 13-year-olGerman
d shepherddog. N oti c e
that nonmi nera i zedstructuresare more di ffl cul to
t defrneov "-
i ng to a smaler ai r space.
I Trachea
Anatomic considerations
The trachea is easiestto evaluate on the lateral viewl however, its
appearanceon the ventrodorsalview is useful for assessmentof
displacement.The tracheais essentiallya midline structure,but it
is normally found slightiy to the right in the cranial mediastinum.
This deviation is more exaggeratedin brachycephalic breeds and
obese dogs; this normal deviation should not be mistaken for
displacement due to a mass. On the laterai view, the trachea is
nearly parallel to the cervical spine, but it is slightly closer to the
spine in the caudal cervical region than in the cranial region.
Becausethe thoracic vertebrae angle dorsally, there is slight diver-
gence of the trachea from the thoracic spine. The trachea angles
slightly ventrally at the point of bifurcation into the principal
bronchi. The diameter of the trachea is relatively uniform, and is
slightly smaller than that of the larynx. In normal animals, the
trachea does not vary significantlybetween phasesof respiration
and remainsunilorm in diameter.
The trachea is a semirigid tube attached at the larynx and the
Figure 263. A latera radiographof the pharyngearegion
of a /-year-ol dLabrado"erreve w ,rl - dysp^ea.A r^eopas ti c
mass 1 cm i n di ameter(arrow s)w as foundradi ographi c al and ly
confl rmedby endoscopi examl c nati on and at surg ery Les
. i ons
i n thl s area may be easl y overl ooked, on underex -
especi al ly
posedradi ographs. N oti cethat on thi s radograph,t he epi gl ottl s
is posi ti oned
i n the ventra pharynx at the baseof th e tonguere
ql on.
,-ffirrrJ

carina. It is less constrainedby surrounding tissuesin the cranial
mediastinum than in the cervical region. During radiographic
examination in the lateral view, the head and neck should be placed
in an erect, but not overextended,position. Extreme extensionof
the neck may cause compression and narrowing of the trachea at
the thoracic inlet. Conversely,if the neck is flexed, the trachea is
likely to bend in the cranial mediastinum, simulating displacement
by a cranial mediastinalmass (Fig. 26-4).
Mineralization of the tracheal rings may be seen as part of the
aging process, especially in large and chondrodystrophic dogs;
however, it is also seen in younger dogs, apparently with no
significance. Diseasesthat stimulate metastatic mineralization may
stimulate increasedmineralization of the trachea alons with other
soft tissues.
Tracheal displacement
As was mentioned earlier, displacement of the trachea is a reliable
sign of masslesionsin the surrounding soft tissueafter positioning
artifacts and breed variation have been considered. In the cervical
region, mass lesions must be relatively large to cause tracheal
displacement.Unless massivein size, mass lesions that compress
the trachea usually involve the trachea rather than simply touch it.
Except for tracheobronchial and cranial mediastinal lymphaden-
omegaly and gross heart enlargement, compressivemassesusually
originate within the trachea itself.
Figure 264. A, Lalera radiographof a dog wth the head
an d n e c kc o r r e c t l yp o s itio n e d8., L a te r arla d io g r a pohf th e sa m e
do g w i t h t h e n e c kf l e xe d .No ticeth e va r ia tio nin tr a ch e apl o si-
t io n .T h i sn o r m a vl a r i atio nm a y b e d r a m a tic,le a d in gto m isd ia g-
no s i s o f a m e d i a s t i n am l a ss. No tlcea so th a t o n th e fle xe d
v i e w ,t h e l a r y n g e ar le gio nis d lfficu ltto in te r p r e t.
The Larynx,Pharynx,and Trachea 325
Tracheal/laryngeal tumors
Primary tumors of the larlrr-x or trachea are uncommon. In the
canine and feline trachea,osteochondromaand carcrnoma,respec-
tively, are the most common types. Carcinoma is the most common
tumor of the canine larynx, whereas ll.rnphosarcoma is the most
common feline laryngeal tumor. Tiacheal and laryrgeal tumors
often produce clinical signs that are consistentwith airway obstruc-
tion. Most laryrgeal and tracheal tumors appear as masseswithin
the lumen of the airway. Neoplastic lesions must be differentiated
from pollps or abscesseswithin the upper airway because these
may appear radiographically identical to primary tumors.6
Tracheal hypoplasia
Tracheal diameter varies slightly from breed to breed; however, this
variation is minimal relative to the size of the animal. Enelish
bulldogs have a smalier tracheal diameter than do other brJeds,
but are also more likely to have congenital tracheal hypoplasia.'
Calculation of the ratio of tracheal diameter to thoracic inlet
diameter can be used as a way of assessingtracheal size.8 In
nonbrachycephalic dogs, the mean ratio of tracheal diameter to
thoracic inlet diameter was 0.20 + 0.03, compared with 0.16 +
0.03 in nonbulldog brachycephalicbreeds, and 0.13 + 0.38 in
bulldogs. The range in bulldogs was 0.07 to 0.21. The smallest
ratio in bulldogs with no clinical signs of respiratory diseasewas
0.09. The ratio for dogs younger than I year of age was slightly
326 NE CKA ND T H OR AX -C OMP AN IO A
NN IMA LS
smallerthan for older dogs.Accuratelateralpositioningis necessary
for accuratemeasurements.
Tracheitis
Airway infections do not usually result in detectablethickening of
the tracheal wall or narrowing of the lumen. Rarely, acute dyspnea
may occur as the result of inflammatory tracheal disease,with
significantdecreasein diameterof the tracheallumen. If the esoph-
agus contains large or small amounts of gas, the esophagealwall
may cause a silhouette sign with the dorsal tracheal wall (tracheo-
esophagealstripe sign), presentingan erroneousappearanceof
trachealthickening (Fig. 26-5).
Tracheal collapse
Most tracheal problems are dynamic in nature, resulting in varia-
tion in tracheal size related to the phase of the respiratory cycle,
that is, trachealcollapse.nThis variation is most often seenin toy
dog breeds becauseof weaknessin the structural rigidity of the
trachea. Tracheal collapse,becauseof its dynamic nature, requires
special attention for radiographic documentation.
Dynamic narrowing of the tracheal lumen due to tracheal insta-
bility occurs in the cervical trachea (especially at the thoracic
inlet) during inspiration (Fig. 26-6), and in the thoracic trachea
(especiallyat the carina) during expiration (Fig. 26-7). With severe
loss of rigidity, the site of collapse may not correlate with the
phaseof respiration.At times, the area that collapsesmay actually
"balioon" during the oppositerespiratoryphase.
Abnormal enlargementof a portion of trachea on inspiration
should lead to suspicion of obstruction of air flow cranially.This
1*1;---..
lriii6]]:i:i:
enlargement may result from an obstruction in the trachea or
larynx. It is often seen as a secondary radiographic sign of laryn-
geai paralysis.5
Confusionmay occur when trachealrings or a partial air column
can be identified dorsal to the upper margin of the tracheal air
column. Although some believe this is caused by overlying struc-
tures, tracheography(with injection of contrast medium into the
trachea) has proved narrowing of the tracheal lumen tn some
instances.An explanation for this pattern is the redundancy of the
trachealis muscle as it folds into the dorsal trachea, thereby nar-
rowing the actual air space.During fluoroscopic examination, the
soft-tissuetrachealismuscle sometimesmoves into and out of the
lumen during respiration.This radiographic pattern may be seen
in large dogs with no evidenceof respiratorydistress;thus, muscle
laxity is difficult to blame for the radiographic phenomenon in all
dogs. Becausethe dorsal aspect of the trachea may be flattened
normally, a similar pattern may be seen if the trachea is rotated
(Fig. 26-8).
For full evaluation of dvnamic tracheal disease.lateral radio-
graphs should be made during both inspiration and expiration.
Abnormalities in the thoracic trachea are exaggeratedduring
coughing. Fluoroscopicexamination may be necessaryto demon-
strate the dynamic signs.
Narrowing of a region of the tracheahas been reported in cats
secondary to localized obstruction in the cranial aspect of the
trachea.r0The cause for this localized obstruction may not be
radiographicallyvisible,suggestingthat discoveryof a narrowed or
collapsed trachea in cats should prompt further investigation by
meansof endoscopicexamination.
Figure 26-5. /, Lateralradiograph of a 9-month-oldretriever.
B ecauseof the gas i n the crani alesophagus, the v entrales oph-
agea w al l and the dorsaL trachealw al l si l houettei nto one s oft-
ti ssue opaci tythat may be erroneousl yi nterpretedas thi c k -
en ng of the trachealw al l . B , Lateralthoraci cradi ograph of an
11-year-olWest
d H i ghand w hi te terri er.A barey di s c erni bl e
amountof gas i s presenti n the thoracc esophagus(arrow s ).
B ecauseof thi s gas, the ventralesophagealwal i s , agai n,
si houettedagainstthe dorsaltrachealwall (arrowheadd.fhts
is calledthe trachea-esaphageal stripeslgn. Gas is often found
i n the esophagus at thi s ocatl on.
::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

Figure 26-7. Inspiratory/A/ and expiratory/B/ radiographs

o f a n ' 11 - y e a r - o lpdo ode . T h e e n tir eth o r a cictr a ch e aco lla p ses
. m a n y p a tie n ts,o n ly th e
n e a r l yc o m p l e t e l yd u r r n ge xp ir a tio nln
ca u d a lt r a c h e ac o l l a p se s, with a ch a r a cte r istce n d - e xp ir a tory
" c l i c k " h e a r do n a u s cu lta tio n .
32A NE CKA ND T H OR AX -C OMP AN IO A
NN IMA LS
Recently,tracheal rupture due to overdistention of the endotra-
cheal tube cuff during anesthesiahas been reported in cats (see
Chaoter 30).
Diagnostic ultrasound is not commonly used for assessingthe
trachea or larynx, but in experiencedhands this modality may be
useful.r1,r5
References
1. O'Brien JH, Harvey CE, Tucker lA: The larlnx ofthe dog: Its nornal radiographic
anatomy. I Am Vet Radiol Soc 10:38, 1969.
2. Gaskell Cl: The radiographic anatomy of the pharlnx and larlnx of the dog. I
Small Aaim Pftct 14:89, t974.
3. Berry CR, Gallaway A, Thrall DE, Carlisle C: Thoracic radiographic features of
anticoagulant rodenticide toxicity in 14 dogs. Vet Radiol llltrasound 34:391' 1993.
4. Peterson J, Streeter V: Larlngeal obstruction secondary to brodifacoum toxicosis
in a dog. I Am Vet Med Assoc 208:352, 1996.
5. Reinke JD, Suter PF: Larlngeal paralysis in a dog. I Am Vet Med Assoc 172:714,
1978.
6. Carlisle CH, Biery DN, Thrall DE: Tiacheal and larlngeal tumors in the dog and
caf Literature review and 13 additional patients. Vet Radiol 321229'1991.
7. Suter PF, Colgrove DJ, Ewing GO: Congenital hypoplasia of the canine trachea. l
Am Anim Hosp Assoc 8:120, 1972.
8. Haney CE, Fink EA: Tracheal diameter: Analysis of radiograPhic measurements
in brachycephalic and non-brachycephalic dogs. J Am Alim Hosp Assoc 18:570,1982.
9. ]ohnson LR, McKiernan BC: Diagnosis and medical management of tracheal
collapse. Semir Vet Med Surg (Small Anim) 10:101, 1995.
10. Hendricks IC, O'Brien JA: Tracheal collapse in two cats. I Am Vet Med Assoc
1 8 7 : 4 1 8 ,1 9 8 5 .
11. Rudorf H: Ultrasonographic imaging of the tongue and larlnx in normal dogs. J
Small Anim Prcc|38t439, 1997.
12. Rudorf H, Herdage XM, White RA: Use of ultrasonography in the diagnosis of
tracheal collapse. J Small Anim Pract 38:513, 1997.
13. RudorfH, Brown P: Ultrasonography oflarlngeal massesin six cats and one dog.
Vet Radiol l]ltrasound 39:430, 1998.
Figure 26-8. lllustrationof rotatedtracheain cross section /topl
and expectedradlographicresults /bottomr.fhe black curved arrow
indicates rotation of the trachea. fhe white dashed arrows indicate
x-rayphotonspassingthroughtwo differentareasof the trachea.The
regionwhere the beam passesthroughless trachea(thusmore soft-
tissue or fat) will appearmore radiopaquethan the regionwhere the
beam passesthroughthe entire trachealdiameter.On a lateralview
of the neck,the tracheallumen may appearnarrow,whereasmineral-
izedtrachealringscan be identifieddorsally.This appearancehas not
beenprovento i ndi catetrachealcol l apse.
14. Bray IR Lipscombe VL White RA, Rudorf H: Ultrasonographic examination of
the pharynx and larlmx ofthe normal dog. Vet Radiol Ultrasound 39:566,1998.
15. Rudorf H, Lane JG, Wotton PR: Everted larlngeal saccules: Ultrasonographic
findings in a young Lakeland terrier. J Small Anim Pract 40:338, 1999.
ffi Ouestions
1 Laryngeal and pharyngeal structures may be difficult to distin-
guish on high-quality radiographs in which of the following?
A. Young animals
B. Obeseanimals
C. Brachycephalicbreeds
D. All of the above
2. Trtte or False.Mineralization of larl,ngeal structures is abnor-
mal if seen in dogs younger than 5 years of age.
3. Tiue or False.Except during swallowing, the normal epiglottis
is usually seen in radiographs to be flat against the ventral wall of
the pharlmx.
4. Tiue or False.Soft-tissue opacity or mass effect lesions within
the gas-filled chambers of the larynx or pharynx may be causedby
neoplasia, abscess,pol)?s, or foreign objects.
5. Tlue or False.The volume of the pharynx may be compromised
neoplasia,
by outside material, including adipose tissue, abscesses,
or enlargement of tissuessuch as lymph nodes.
6. True or False. The trachea is a midline structure. Deviation
from the midline is abnormal on a ventrodorsal (dorsoventral)
view in any patient.
7. True or False.When a radiograph of the trachea is taken, to

'avoid
erroneouscompressionof the trachealdiameter,the patient's
neck should be flexed.
8. True or False. Normal tracheal lumen diameter relative to
thoracic inlet diameter is smaller for brachycephalicdogs than for
nonbrachycephalicdogs.
9. True or False.If demonstratedradiographically,"tracheal col-
CHA P T E R
27
The Esophagus
r Barbara Iean Watrous
Disorders of the pregastricalimentary tract result in a variety of
clinical signs, including regurgitation, dysphagia, abnormal swal-
lowing, and gaggingor retching. Other signs include weight loss,
failure to gain weight or grow normally, and chronic or recurrent
respiratory problems. Aspiration pneumonia, tracheitis,and nasal
discharge are frequent complications of esophagealdysfunction.
In several systemic neuromuscular diseases,the oropharynx, the
esophagus,or both may be involved. Indications for evaluationof
the upper alimentary tract, therefore, include dysphagia;regurgita-
tion; and recurrent, unexplainedrespiratorytract infections.
I Esophageal anatomy
The esophagusis a musculomembranoustube bounded at each
end by a sphincter. The four layers include the mucosa, a keratin-
ized stratified squamous epithelium with infrequent pigmentation
in selectcaninebreeds(e.g.,Chow Chows);the submucosa,a loose
network of fibrous connective tissue with varying quantities of
smooth muscle and mucous glands; the muscularis, which is com-
posed of striated muscle in the dog (the terminal one third is
smooth muscle in the cat, with its correspondingmucosa thrown
into obliquely directed folds); and the adventitia.
The cranial esophagealsphincter is composed of paired crico-
pharyngeal muscles and paired thyropharyngeusmuscles.These
form an annular band attachedto the dorsal aspectof the larynx
and serveto prevent reflux of esophagealcontents into the pharprx,
thereby minimizing aerophagiaduring respiration.
The caudal esophagealsphincter is a complex structure that
comprises the following: focal thickening of the inner circular layer
of esophagealsmooth musciefrom the muscularis;a confluenceof
gastricrugal folds that lie transverseto the junction; and a muscu-
lar sling created by the right crus of the diaphragm on the right
and the deep oblique smooth muscle layer of the lesser curvature
of the stomach on the left. The complerity of this sphincter can be
attributed to the effect of the oblique implantation of the esopha-
gus into the stomach, as well as to the relatively positive intra-
abdominal pressure that compressesthe short intra-abdominal
segmentof the terminal esophagus.
Ir Normal radiographic
appearance
The normal esophagusis difficult to see radiographically (Thble
27-1) becausethe soft tissuesof the cervicalesophagussilhouette
with surrounding musclesand associatedfascia,and the thoracic
esophagus is enveloped by the dorsal mediastinum, fascia, and
The Esophagus 329
lapse" tends to occur during inspiration in the cervicalregion and
during expiration within the thora-x.
10. Tiue or False. Normal gas in the esophagusmay lead to
erroneousdiagnosisof trachealwali thickening.
Answers begin on page 727.
connectivetissue.IAccumulation of intraluminal gas usually indi-
catesesophagealdisease.Occasionally,however,small amounts of
swallowedair are seenin the normal esophagus.Common sitesfor
this on the lateral view include the area immediately caudal to the
cranial esophagealsphincter (Fig. 27-I), regionsat the level of the
thoracic inlet, and those dorsal to the heart base. Aerophagia
occurs most often in apprehensive,sedated,and dyspneicanimals.
In subsequent radiographs, it typically is apparent that this focal
air accumulation is transient. In the dorsoventralor ventrodorsal
view, this gas is often hidden becauseof superimposition. General
anesthesia may cause marked dilation of a normal esophagus,
mimicking megaesophagus. The induced pulmonary atelectasis
also mimic aspirationpneumonia. For these reasons,use of anes-
may
thesia for thoracic radiographyis not recommended.t
The absenceof abnormal esophagealradiographicfindings does
not preclude the presenceof esophagealdisease;such is often the
casewith acute esophagealdisease.In addition, the presenceof
indirect signs of esophagealdiseaseshould be anticipated. For
example,focal or generalizedesophagealdilation may be less ap-
parent when the lumen is fluid-filled, creating a positive silhouette
sign with the surrounding mediastinum.
I Esophageal contrast studies
Contrast radiographic examination is often necessaryfor accurate
identification of lesions or for further characterization of survey
radiographic findings. Differentiation of functional from morpho-
logic causesof dysphagia may be possible with static contrast
studies. Specific evaluation of functional abnormalities, however,
may be possible only with dynamic fluoroscopic studies, or with
other imaging modalities such as nuclear scintigraphy. The empha-
sis in this chapter is on information provided by static survey and
conlrast radiographicfindings.
Gontrast media
Many contrast media are available for esophagography,and selec-
tion of a specificone should be based on the suspecteddisease.l
Barium sulfate cream and paste (e.g., Esophotrast,Intropaste,EZ
Paste,and Varibar) have been formulated for extreme radiopacity
and to enable good adherence to esophageal mucosa. Mucosal
irregularities(e.g.,esophagitis,neoplasticinfiltrates) and strictures
are readily evaluatedwith pasteor cream.Becauseof their viscosity,
however, they tend to maintain a bolus, failing to disperse well or
flow around intraluminal lesions.Admixture with licuid barium
suspensions is alsopoor, resultingin clumping in the gastriclumen
when an upper gastrointestinalexamination using liquid barium
33O NE CKA ND T H OR AX -C OMP AN IO A
NN IMA L S

Table 27-1. Survey radiographic findings

Radiographicfindings Esophagealstatus Etiologies
Norma l No r m a l
Abn o r m a l N e u r o m u s c u l a dr i s e a s e
H i a t a lh e r n i a
F o r e i g nb o d y ( n o n r a d i o p a q u e )
Esophagitis
Early strictures
Fistulas
Radiolucency
Reg ion alint r alum inal No r m a l Aerophagia
Ab n o r m a l F o r e i g nb o d i e s ( n o n r a d i o p a q u e )
Gastroesophageal intussusception
Extraluminalmasses
Esophagitis
Strictures
V a s c u l a rr i n g a n o m a l i e s
Neoplasia
Segmentalhypomotility
Gen er aliz edint r alum inal No r m a l Generalanesthesia
Centralnervoussystem depression
Megaesophagus
Ab n o r m a l N e u r o m u s c u l ah r ypomotility
Hypoadrenocorticism
Autoimmune myositis
Autoimmuneneuritis
Myastheniagravis
Toxicities
Neoolasia
Hypothyroidism
Trauma
Periesophageal No r m a l Subcutaneousemphysema
Ab n o r m a l Perforation
Radiopacity
Reg ion alint r alum inal Ab n o r m a l V a s c u l a rr i n g a n o m a l i e s
F o r e i g nb o d i e s ( r a d i o p a q u e )
Spirocerca lupi
Neoplasia
Gastroesophageal i ntussusception
Diverticula
Periesophageal masses
Ge ne r aliz edint r alum inal Ab n o r m a l Megaesophagus

Figure 27-1. Lateralview of the neckof a normal6-week-oldpuppy

thatstruggl edduri ngradi ographiexami
c A i r trappe di n the c rani al
nati on.
esophagus(arrow)jusl behind the cranialesophagealsphincter/dou-
bleheadedarrow)iscommonlyseen underthese circumstances. {Cour-
tesy of New YorkState Collegeof VeterinaryMedicine,lthaca,NY)

sulfate suspensionfollows an esophagramin which paste was used.
Aspiration of pastemay lead to asphlxiation; therefore, use of paste
is not advised when aspiration is a concern.
Liquid barium sulfate suspensions (e.g., e z hd, Liquid Sol-O-
Paqtte, E-Z-Paque, Novopaque, and Flexi-Bar) do not adhere well
to the mucosa; however, a high-density contrast medium (45o/oto
85o/odw) can be used for esophagographybecauseit is relatively
safe when aspirated, mixes well with fluid contents, and readily
flows around obstructions. Motility problems in the oropharyngeal
and esophagealregions should be evaluated first with liquid bar-
ium. Barium-coated food may be administered subsequently,par-
ticularly in animals with problems in swallowing solids but not
liquids. Barium-coated food may be the best choice for identifica-
tion of early strictures or regional motility disorders.
Oral aqueous iodine solutions (e.g., Gastrografin, Oral Hlpaque
Sodium, and MD-Gastroview) are relatively nontoxic in body cavi-
ties. Therefore, their use is indicated when esophagealperforation
is suspected.These agents are hypertonic; thus, if aspirated, they
may induce pulmonary ederna. In addition, because of their os-
motic effects, a volume-depleted animal may be further compro-
mised by fluid loss through the gastrointestinal tract. If leakage
occurs into a fluid-filled pleurai spaceor if the leak is minimal, the
resulting dilution may make it diffrcult to detect the extravasated
contrast medium or the site of leakage (Fig. 27-2). Nonionic
organic iodide agents (e.g., Omnipaque) are isosmolar and are not
associatedwith the complications encountered with ionic contrast
media, but they are considerably more expensive.Use of a barium
sulfate liquid in the presenceof a perforation is a practice that has
instigated some controversy becauseof the tendency of barium to
stimulate a granulomatous reaction on pleural surfaces.The use of
barium sulfate is indicated, however, when oral iodinated contrast
medium fails to define the problem. Aqueous iodine contrast media
are not recommended for routine esophagographybecauseof their
poor coating ability.
Technique
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
of the esophagusand surrounding tissues. Superimposition of the
spine readily obscures even a barium-coated esophageallumen.
Therefore, in addition to the lateral view, an oblique view such as
a dorsoright-ventroleft or dorsoleft-ventroright view is recom-
mended to rotate the esophagus into a more visible location.
On the lateral view, the opacity over the thoracic inlet from the
Figure 27-2. Lateralsurveyand contrastradiographs
to treat chronic congenitalesophagealhypomotilityand megaesophagus.
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
The Esophagus 331
musculature of the brachium can be reduced by moving one
thoracic limb cranially and the other caudally. Survey radiographs
should include the cranial esophagealsphincter dorsal to the iar-
ynx, the cervical and thoracic esophagus, and the short intra-
abdominal esophagealsegment and caudal esophagealsphincter
within the cranial abdomen.
A fractious animal may be given a nominal dose of phenothi-
azine tranquilizer (e.g., acepromazinemaleate, 0.05 mg/lb of body
weight subcutaneously or intramuscularly). However, the esopha-
gus is affected by most central nervous system depressant drugs;
therefore, their use is disadvantageouswhen motiliry is being evalu-
ated. Approximately 5 to 20 mL of contrast medium is given to
induce several complete swallows for coating the pharlnx and
esoPnagus.
Oropharyngeal problems are best evaluatedby a series of radio-
graphs made in the midst of a swallow and during a pause after
the swallow is completed. The esophagealphase can be evaluated
by an additional radiograph that is made after a sufficient pause to
ensure complete transport of the last bolus to the stomach.
The normal appearance of the oropharyngeal region after a
swallow of contrast medium revealscoatins of the mucosa without
significant retention of the contrast medirim (Fig.27-3). A small
amount of contrast medium may occasionallvremain in the esooh-
ageallumen immediatelycaudal to the cranial esophageal sphiniter.
No contrast medium should persist in the piriform recessesor
nasopharprx, larynx, or trachea unless laryngotracheal aspiration
inadvertently occurs.
The normal canine esophagealmucosa appears as a series of
longitudinal folds. The lines are close together through most of its
lengrh but may separateslightly at the thoracic inlet is the esopha-
gus passesalong the left lateral side ofthe trachea(Fig.27-a).The
feline esophagushas a similar appearanceto the leveLof the heart
base, but the caudal esophagushas obliquely directed folds that
correspond to the smooth muscle segment (Fig. 27-5). Oblique
views eliminate superimposition of the spine and sternum for
better visualizationof the esophagus(Fig. 2l-6).tzt
I Oropharyngeal dysphagia
Sruallowing disorders related to the oropharl,ngeal phase may be
due to abnormalities of the tongue, the pharynx, and the cranial
es,ophagealsphincter. Identification of the underlying disorder,
when functional, may be difficult, but indirect evidence is often
inferred when oral or pharyngeal retention of contrast medium
occurs. Mechanical causesof oropharyngeal dysphagia are uncom-
of a 4-year-olddog 2 days after a myotomyat the gastroesophageal
junction.The myotomywas intended
A, Dehiscenceresultedin esophagealleakage,pneumonia,and pleuriiiswith pleural
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

Figure 27-3. Normal oropharyngealcontrast nredium examination

of a maturedog (l ateravi ew ).B , baseof tongue;C rE S c, ranraes opha-
gealsphi ncter;E , esophagus; L, arynx;N P ,nasopharynx OP
; ,orophar
ynx; PR, piriformrecesses;T, trachea,V, valleculae.(Courtesyof New
Y orkS tateC o l egeof V eteri nary
Medi ci ne,l thaca,N Y )

Figure 274. Norma esophagram(lateralview) of a maturedog

us rn gb a r i u ms u l f a t ec r e a m .T h e lo n g itu d in afol ld s o fte n se p a r ate
at t h e t h o r a c i ci n e t .

Figure 27-5. Normal caudalthoracic esophagramin a mature

mucosalpattern.
cat. N otethe herrl ngbone
 The Esophagus 333

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-
rations of the oral cavity or pharlnx by sticks and infiltrative
lesions. These mechanical causesare often best identified with a
thorough visual examination. Functional abnormalities are usuaily
characterizedby unremarkable survey radiographic findings.
Diseases of the oral stage of swallowing usually involve the
tongue. If an abnormality of the oral stage is present, the effect
may be noted on prehension, during caudal transport through the
oral cavity, or by organization of a bolus in the oropharynx by
the tongue. Retention of contrast medium in the oral cavity and
oropharl'nx can be seen radiographically. The subsequentpharyn-
geal and cricopharlmgeal stagesare normai (Fig.27-7).
Pharyngeal stage dysphagia is associated with neuromuscular
disease,inflammatory disease (Fig. 27-B), and trauma that may
result from perforation (Fig. 27-9) or from fracture of the hyoid
apparatus (Fig. 27-10). The oral stage is normal, but inadequate
pharyngeal peristalsis leads to retention of much of the bolus of
contrast medium. Inadequate closure of the pharyngeal egresses
(nasopharynx, oral cavity, and larlrrx) may lead to reflux o?.otr-
trast medium into theseregions.
Cricopharyngeal stage dysphagia may be due to inappropriate
opening or nonopening of the cranial esophagealsphincter (crico-
pharyngeal aslmchrony or achalasia) or failure of closure of that
sphincter (chalasia). Chalasia is recognized by the persistenceof a
patent passagebetween the pharl,nx and cranial esophagus (Fig.
27-11). Reflux of esophagealcontrast medium results in its pres-
ence in the pharynx. Pharyngeal paresis, which is an additional
causefor pharyngeal retention of contrast medium, often accompa-
nies cricopharyngealchalasia.Dysfunction of the cranial esophageal
sphincter becauseof asynchrony or achaiasiaresults in interference

Figure 27-7. Lateralview of a maturedog with oraldyspha-

gia owing to a hypoglossalneuropathy.Inadequatestripping
action of the tongue againstthe hard and soft palateprevents
caudal transport of ingesta,and there is no resultingbolus
formation of contrast medium at the base of the tongue. A
small amount of contrastmedium has been swallowed,signi-
fying normal pharyngealand cricopharyngeal function. iCour-
tesy of New YorkState Collegeof VeterinaryMedicine,lthaca,
NY )
334 NE CKA ND T H O R AX -C OMP AN IO A
NN IMA LS

o.n
tu
.l "
.rll1l:..iiiiilr:;
i!l

r1,,,,:1!ll
ji,,;; :r,
lr:i+ru:: *:li$tl,l:l

Figure 27-8. pharyngealstagedysphagiais a resultof inadequatesequentiacranial-to-caudal contractionby the pharyngeamuscles.Thus,transportof a bo us

t h; o u g ht h e c r a n i ael s o fh a g e aipl h in cte ris u su a llyin co m p le teContrast
. medi uml s retai nedi n the pharynxand pi rform recesses. Thi sdog w i th ch roni cl ary ngi ti s
trac hea.
i llin ga n d in fla m m a tiornn addi ti onto scarri ngof the l arynx.A , N otethe shortepi gl otti sand the ventral l ydi s pl ac ed
and p i a r y n g i t i sh a s r e t i op h ir yn g e aswe
A ir is r e t a i n ; di n t h e e s op h a g u s.B, Eso p h a g r a mth; e r eis p h a r yngeal
retentl onof contrastmedi umand l aryngotrachea aspi rati on becauseof di stu rbedmoti l i ty .

{T$T

Figure 27-9. Pharyngeallacerationsecondaryto a strck resultedin

a retropharyngeal fi stul aand pharyngeal
paresi s.Therei s ac c umul at
on
of contrastmed um i n the pharynx,the pi ri formrec es s es and , the
retropharyngeaabscess.D oubl eheadedarraw denol esthe c ranl al
esophagealsphincter.(Courtesyof New York State Collegeof Veteri
narvMedi ci ne.l thaca.N Y )

Figure 27-1O. Lateralview of the pharyngealregionof a mature

dog .T h e h y o i da p p a r a tu p s la ysa n in te g r arl o le in co o r d in a tinlaryn-
g
a l gesof
gea lc l o s u r ew i t h t h e o r a l,p h a r yn g e aa, n d cr ico p h a r yn g esta
swa lowing. FrccrLre(arrowslor dislocationof the hyoid apparatus
ma v d i s r u p tt h i s p r o c e ss,a s in th is d o g . Co n tr a stm e d iu mh a s col -
lec t e d i n t h e o r o p h a r vn xb u t ca n n o tb e p r o p e lle dca u d a llyb y the
pharynx.(Courtesyof New YorkStateCollegeof VeterinaryMedicine,
I t h a c aN
. Y)
 The E sophagus335

Figurc 27-11. Lateralview of the pharyngealregronof a mature

dog with autoimmune polymyositis.Chalasia(arrowsl and mega
e s o p h a g u sa r e p r e se n t.Co n tr a stm e d iu min th e va lle cu la and e p ri -
f o r m r e c e s s e sm a y b e d u e to e so p h a g o p h a r yn g er eaflu x o r to pha-
r y n g e a lo a ' e s i s .l C o L r te syo f \e w vo r k Sr a teCo lte g eo ' Vereri rary
M e d i c i n e l.t h a c a N . Y)

with transport of the contrastmedium. The passagemay be visibly Foreign bodies

distorted, although the pattern of distribution of retained contrast
medium is similar to the pattern found in pharyngeal dysphagia
(Fig. 27-12). Tab\e 27-2 provides a summary of the static contrast
radiographic findings in the various oropharl'ngeal dysphagias.'
I Megaesophagus
Segmental megaesophagus
Segmentalesophageal diseasemay be due to congenitalor acquired
causes and may be either functional or mechanical. Frequently,
segmental disease is identified on survey radiographs by focal
air accumuiation.Abnormal regional air accumulationmay occur
anywhere along the esophagusjust cranial to or at the site of
localizeddisease.Air often is noted at the site of acute entrapment
of intraluminal foreign bodies,esophagitis,and segmentalesopha-
geal hypomotility. Obstruction of the esophageallumen by vascular
ring anomalies (Fig. 27-13), acquired strictures (Fig. 27-14), extra-
luminal (Fig. 27-15) and intrinsic masses,and chronic foreign
bodies may or may not result in air accumulation. In chronic
disease,fluid, a mixture of fluid and air, or a heterogeneouspattern
of food accumulationmay be seen.6'7
Entrapment of foreign bodies within the esophageallumen is a
common causeof esophagealdysphagia.Ingestionof nondigestible
material or piecesof food too large to passthrough the esophagus
can lead to entrapment. Typical features of obstructing foreign
objects include a firm or rigid consistency; a sharp, angular, or
spiculatedshape (Fig. 27-f6); or a large size relative to the least
distensibleregionsof the esophagus.Bones,fishhooks,and needles
are common esophagealforeign objects. Less common foreign
objectsinclude linear foreign bodies and trichobezoars.The usual
entrapment sites are the cranial cervical region, the thoracic in1et,
the heart base, and the caudal thoracic esophagusin the region
cranial to the esophagealhiatus.
Survey radiographs may allow identification of radiopaque for-
eign bodies. The survey radiographic examination should include
views of the entire esophagus,including the caudal pharp-rx and
cranial abdomen. Exposureappropriatefor evaluation of the lung
and pleura is important to rule out sequelaeof esophagealdisease,
including aspirationpneumonia, perforation of the esophagusand
secondarypleuritis, mediastinitis,or pulmonary fistula.When sus-
picion of a foreign body is not supported by survey radiography,
an esophagram often results in accumulation of contrast medium
in the immediate area of the foreign body and the secondarily

Figurc 27-12. Lateralesophagramof the pharyngealregionof a

d o g . D u r i n gt h e p h a r yn g e aal n d cr ico p h a r yn g e asta l g e s o f sw al -
lo w i n g t, h e p h a r y n xi s in vig o r o u sco n tr a ctio /a
n r r o wla g a in sta cl osi ng
cr a n i ael s o p h a g e aslp h in cte (r CP) T . h e fo o r o f th s p a ssa g eis open,
a l l o w i n ga i r a n d c o n tr a stm e d iu mto o u tln e th e d isto r te dsp hi ncter.
T h i s a s y n c h r o n yb e t we e n th e p h a r yn g e aal n d th e cr ico p h aryngeal
st a g e so c c u r sm o r e c o m m o n lyth a n d o e str u e cr ico p h a r yn geal acha-
la s i a .B T , b a s e o f t o n g u e ;E, e so p h a g u s; T , tr a ch e a WA,
; wings of
a t a s . ( F r o mE t t i n g erSJ ( e d ) :T e xtb o o ko f Ve te r in a r yIn te r n all \,4edl -
c i n e ,2 n d e d . P h i a d e lp h iaWB, Sa u n d e r s, 1 9 8 3 .)
336 NE CKA ND T H OR AX -C OMP AN IO A
NN IN /ALS
Table 27-2- Summary of location of retained contrast medium relative to type of oropharyngeal dysphagia
Site Normal Onat
Oral cavity +l- +
Nasopharynx
Oropharynx T
Pharynx
Valleculae +l-
Piriform recesses
Eso ph ag us
Larynx/trachea
+, present; , absent.
segmentally dilated esophagus (Fig. 27-17). Foreign bodies can
cause complete, partial, or no obstruction, with obstruction oc-
curring most often at sites of limited esophagealdistention. They
may induce esophageallaceration when they are sharp or spiculated
or when chronic, leading to mural necrosis.In the cervical esopha-
gus, a tear leads to leakageof luminal contents, which may widen
the retrotracheal soft-tissue space and facilitate the escapeof air
into tissues.Secondaryabscessmay develop. If the tear is intratho-
racic, pneumomediastinum (Fig. 27-18) and occasionally axillary
air may be seen. Chronic perforation is associatedwith exudation,
producing mediastinitis and pleuritis.
Esophageal and periesophageal masses
(neoplastic/i nflammatory)
Intrinsic massesof the esophagusare uncommon. They may be
benign or malignant neoplasms or inflammatory masses.The inci-
dence is greater in certain geographic regions, specifically areas
endemic for Spirocercalupi. Branchiomas, branchial cleft rysts,
papillomas, metastatic tonsillar carcinomas,and squamous cell car-
cinomas occur rarely. The presenceof a benign leiomyoma may be
recognized only at necropsy owing to its slow growth rate and lack
of invasiveness;however,when this tumor is encounteredon survey
thoracic radiographs, it may be seen as a soft-tissue "stripe" be-
tween the descendingaorta and the caudal vena cava in the caudal
thorax (Fig. 27-19). Mineralization of esophagealmasses is rare
and appears as amorphous linear mineral opacities usually located
in the dorsocaudal thorax (Fig. 27-20). Differential causes for
mineral-like opacities on radiographs include dystrophic mineral-
ization of an inflammatory or neoplastic mass, chronic radiolucent
foreign body with mineralization, and coating of an eroded esopha-
geal mucosa by an orally administered antacid or enteric-coating
agent. These medications contain bismuth and other high-atomic-
number elementsthat are radiopaque.' Pedunculatedmural esoph-
Dysphagia
Pnanvuaeat CarcopnnaYueent
J_
+ +
+ +
+ +
+l-
+ +
agealmassesare very uncommon and may be confusedwith foreign
bodies. They are usually smooth and round to ovoid and may shift
position slightly as peristaltic waves attempt to push the mass
aborally (Fig. 27-21). They do not usually cause luminal obstruc-
tion, possibly becauseof accommodation by the esophagusto the
gradual enlargement that occurs with growth of the mass. Contrast
medium use provides for definition of the mural lesion, with
variable filling defect dependent on the character of the lesion. A
pedunculated mass appearsintraluminal (see Fig. 27-21), whereas
a broad-based mural lesion often oroduces a more subtle and
irregular filling pattern that suggesti wall irregularity with focal
dilation (Fig.27-22) in the absenceof obstruction.
Extrinsic masses may cause displacement and partial to total
obstruction of the esophagus, depending on location. Cervical
masses include thyroid tumors, lymphadenopathy, and cervical
abscesses. Invasion of the esophagusby extension may occur, Iead-
ing to luminal narrowing or wall stiffness and secondary dysfunc-
tion. Thyroid carcinomas may follow the latter course. Intratho-
racic massesmay cause significant luminal narrowing because of
the restriction of spaceby the spine, sternum, and larger mediasti-
nal structures (e.g., the heart). Accumulation of intraluminal air
may be seen cranial to the mass causing the partial or complete
obstruction (see Fig. 27-15). Oral administration of contrast me-
dium will fill the segmentally dilated esophagusand may demon-
strate deviation of the lumen away from the origin of the mass
(Fig. 27-23). Ultrasonography has proved useful in diagnosing
compressivestricture by an extramural mass.Periesophageallesions
may be aspirated or biopsied with ultrasound guidance when visu-
alized on ultrasonography.
Acquired esophageal stricture
Esophagealhealing following trauma or severeinflammation may
lead to scarring and contracture of the wall. A recent history of
Figure 27-13. Lateralview of the thorax of a young dog with a
persistentright-fourthaortic arch. The characteristicsite of obstruction
with persistent right-fourthaortic arch is just cranialto the tracheal
bifurcation(open anow). An evaluationfor possibleesophagealdilation
caudalto the ring, as was presentin this animal (doubleheaded arrow),
must be made. The radiopacities are foreign bodies {stones)within the
prestenoticdilated esophageallumen. Thoracictrachealdepressionis
evi dent.R are causesfor other vascul arri ng anomal i esi nc l udedoubl e
aortic arches,aberrantright subclavianartery,and dextroaortawith left
subclavianartery. (Courtesyof New York State College of Veterinary
Medi ci ne.l thaca.N Y )
 The Esophagus 337

Figure 27-14. Lateralesophagramof a young adult dog. There is

a c r a n i atlh o r a c i ce s op h a g e astr l ictu r eT. h e le sio nd e ve lo p e d
a fterthe
a d m i n i s t r a t i oonf a n e sth e siaT.h e e xte n to f th e lu m in a lin vo l vement
w a s b e s t d e m o n s t r a tebdy p la cin ga n e so p h a g e atu b ewh ile the dog
w a s a n e s t h e t i z eadn d g r a d u a lly a d m in iste r incog n tr a stm e d iu mto fi l l
t h e d i s t e n s i b l ep o r t i o n so { th e e so p h a g u s.( Co u r te syo f Ne w Y ork
S t a t eC o l l e g eo f V e t er in a rM y e d icin elth
, a ca NY),

Figure 27-15. Lateralview of the dorsocranialthorax of a dog

w i th si gns of regurgi tati on.
A thoraci ctumor enc roac hedon the
esophagus,l eadrngto mi l d di l ati onand focal ai r ac c umul arl on
ar
the thoracicinlet (anows).(Courtesyof New York State Collegeo{
V eteri naryMedi ci ne,l thaca,N ' ,

Figure 27-16. Lateralview of the dorsocaudalthorax of a dog.

T h e r ei s a r a d i o p a q ufo e r e ig nb o d y cr a n iato
l th e e so p h a g e al hi atus.
T h e s h a r pp r o j e col n i s ch a r a cte r istico f e so p h a g e afol r e ig nb o di es.A
prominentzone of soft tissue (arrows) surroundsthe bone, indicatrve
o f e s o p h a g e awl a I t hicke n in gb y in fla m m a tio nF. o u rco m m on si tes
o f f o r e i g nb o d y e n t r ap r n e nat r e th e cr a n ia ce
l r vicarl e g io n ,the tho-
ra c i c i n l e t , o v e r t h e b a se o f th e h e a r t,a n d cr a n ia lto th e hi atus.
(Courtesyof New York State Collegeof Vetennarylvledicine,lthaca,
NY)
338 NE CKA ND T H OR AX -C ON l P AN IOANN IMA LS

Figure 27-17. Lateralview of an immaturedog. A nonradiopaque

pi eceof pl asti ci s seenas a fi l l ngdefecti n a poo of co ntras medi
t um.
(C ourtesyof N ew Y orkS tate C ol l egeof V eteri naryMedi c i ne,l thac a,
NY)

Figure 27-18. Lateralview of the dorsocranial thoraxof a mature

dog. E s o p h a g e aple r f o r a tio b n y a b o n e h a s r e su lte din p n e u m o medi -
as t i r - u T T
r .^ e o J t e ' m a r gn s o ' r l- e e so p r a g u sca r b e se e n su p eri r-
posedon the tracheal umen (solidarrows)next to the brachiocepha'
lic artery. A smal bone fragment is visible (open arrow) and was
prese n ti n t h e m e d i a s t i n u m( .Co u r te sy o f Ne w Yo r kSta teCo le g eof
V et e r i n a rM y e d i c i n el,t h a ca N\.r
,

Figure 27-19. Latera view of the caudodorsal thoraxof a mature

dog. There is an area of soft tissue opacitvbetween the aorta and
the caudalvena cava (arrow s).Thi s l s an esophag eall ei omy oma.
(C ourtesy
of N ew Y orkS tateC ol l egeof V etennaryMedi c i ne,l thac a,
NY)
 The Esophagus 339

Figwe 27-20. Survey radiographof the caudodorsalthorax of a

m a t u r ed o g . T h e r ea r e a b n o r m alin l e a rto a m o r p h o u sm in e ra opac-
i t i e s i n t h e d o r s a lt h o r a x.Diffe r e n tiadl ia g n o se sin clu d ed ystrophi c
mineralizatlon f t h e e so p h a g uas sso cia tewithd ch r o n icin fla mmati on
or granuloma(Sptrocerca /upil,neoplasiawith mineraizatlon,chronlc
r a d i o l u c e nfto r e g n bo d y,a n d co a tin go f a n e r o d e dm u co saby an
a n t a c i do r e n t e r i cc o a te da g e n t.( Co u r te sy
o f Ne w Yo r l.Sta teCol l ege
o f V e t e r n a r yM e d i c in elth , a ca NY)
,

surgery should trigger a suspicion because reflux during general
anesthesiamay induce focal esophagitiswith secondaryscarring
and luminal narrowing. Subsequentstenosisproducespartial and
potentiaily completeobstruction with gradual progressionof clini-
cal signs.Dependingon the speedof onset,the severityof scarring,
and the managementof the patient, prestenoticdilation may or
may not be visible on survey radiographs.The diagnosisis usually
made or confirmed using an esophagram(seeFig. 27-14). Persis-
tent narrowing on sequentialradiographs differentiatesthe stricture
from esophagealspasm. Use of barium-coated food bolusesmay
be neededto confirm without doubt the diagnosisof stricture.
Segmental motor disease
Segmentalesophagealdysfunction is uncommonly recognized(in
part becauseof the lack of routine availability of fluoroscopy) but
may occur as a result of trauma or inflammation, or it may be
idiopathic. Segmentalmotility disturbances may affect any portion
of the esophagus.Reflux esophagitisis probably the most common
form of segmentaldysfunction. It usually involves the caudal
esophagusand may or may not be associatedwith hiatal herniation.
These disorders are discussedsubsequently.Diffuse esophagitismay
produce generalized dilation, but it usualiy causes intermittent
esophagealspasm,which mimics stricture, as well as focal dilation
(Fig. 27-2a). Fluoroscopicexamination of the esophaguspermits
evaluation of esophageal function as well as morphology. The
relative strength, rate, and efficiency of contractions can be esti-
mated. In addition, the coordination and function of the cranial
and caudal esophagealsphincterscan be assessed. The evaluation
should include swallows of both liquid and solid boluses, using
three to six complete swallows of each, to observe the possible
differencesin handling of the two consistencies.Nuclear scintigra-
phy may also be considered for evaluation of segmental motor

,'r*afu,;:';:1
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i:,;i;f
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F i g u r e 2 T - 2 1 . A a n d B,An o vo id so fttissu e fillin g d e fecti spresentw i thi ntheesopha-

g e a ll u m e no f a n o ld e rd o g .A p e d u n cu la tetu
d m o rwa s fo u ndon endoscopiexami c natl on.
(C ourtesy
A n e s o p h a g e af o r e r g nb o d ym ig h th a vea sim ia r a p p e a r a nce. of N ew Y orkS tate
C o l l e g eo { V e t e r i na rM
y e d lcln e ,th a ca ,NY)

- 'it r i
i18l
igl
34O NE CKA ND TH OR AX -C OMP AN IOA
NN IMA LS

Figure 27-22. Lateralesophagramof a puppy.The esophageallu-

men i s di l ated.C ontrastmedi umoutl i nesthe di l atedab domi nals eg-
ment, which has a markedlyirregularmucosa surlace (arrowsJano a
fi l l i ngdefect (asteri sk).
The di agnosi sw as granul omatous
es ophagi ti s
with ulceration.(Courtesyof New York State College of Veterinary
Medi ci ne,l thaca,N Y )

Figure 27-23. Lateralesophagramof an immaturecat with cranial

medi a s t i n al yl m p h o s a r c omTah. e p e r ie so p h a g em a la ssca u se so b struc-
t ion o f t h e e s o p h a g u o s w in gto r e str icte d e xp a n sio n ca p a b ilitieast the
l o r a xa n d o win g to th e la r g em a ss. ( From
t hora c i ci n l e t a n d c r a n i a th
E t t in g e rS J ( e d ) :T e x t b o o ko f Ve te r in a r yIn te r n a lM e d icin e ,2 n d ed.
P hila d e l p h iW a ,B S a u n d e r s, 1 9 8 3 .)

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

Figurc 27-25. Schematic of persistent

rightaorticarch.This
view,fromtheleftside,showstheligamentum arteriosum /LAl
connecting the descending rightaortrcarch(RAA) to the main
or ieftpulmonary (PA)
artery causing constrictionof theesopha-
gus /E/ betweenthesestructures andthe heartbase.CVC,
caudal venacava;LAt,leftatrium;LSA,eft subcavian arterv.

disease.Through administration of a small quantity of radioactive
particles per os, such as water labeled with ee"Tc sulfur colloid,
esophagealtransit times, sphincter patency, and reflux can be
observedwith a gamma camera.
Gongenital Gauses of segmental megaesophagus
Vascular ring anomalies. During fetal development of the
intrathoracic vascular structures,the embryologic arch system is
initially duplicated on the right and left sides.Segmentsnormally
persistafter birth and segmentsare transient,with eventualregres-
sion of selectduplicate parts during cardiovasculardevelopment.
The aorta is normally derived from the left fourth arch and por-
tions of the left dorsal aorta. The brachycephalicand right subcla-
vian arteriesoriginate from the right fourth aortic arch and por-
tions of the right dorsal aorta.
The most common malformation leading to entrapment of the
esophagusis persistenceof the right fourth aortic arch; this con-
nects to the main or left pulmonary artery (derived from the
ventral root of the right sixth aortic arch) via the ductus arteriosus
(or ligamentum arteriosusafter birth), which forms from the left
sixth arch. Constriction occurs with the esophagusdorsal to the
heart basebut ventral to the vascularring createdby the aortic arch
locatedrightward, connectingto the leftward pulmonary artery via
the ligamentum arteriosum (Fig.27-25). Dilation of the esophagus
occurs orad to the constriction with abrupt tapering seenat about
the 6th rib. Luminal contents may include air, fluid, and food
material. Occasionally,foreign debris may be retained within the
acquired sacculationsor diverticula (seeFig. 27-I3). Radiographic
signs on the lateral view usually include ventral deviation of the
thoracic trachea (causedby draping of the dilated esophagusover
the dorsum of the trachea) and a distinct interface of the dorsal
wall of the esophagussilhouettingwith the cranialthoracic hypaxial
muscleswhen intraluminal air is present.On the ventrodorsalor
dorsoventralview, the mediastinumcraniadto the heart is widened
and either relatively lucent owing to air in the esophagus,soft-
tissueopaqueowing to fluid accumulation,or heterogeneous owrng
to retained food admixed with air (Fig. 27-26). The trachea is
deviatedto the right. The leftward margin of the descendingaortic
arch is usually absent.In an esophagram,the segmentaldilation of
the esophaguswith constriction of the lumen fust craniad to
the heart base is apparent. A shallow indentation createdby the
contiguous left subclavian artery may be visible craniad to the
constriction on the ventrodorsalview
Rarevascularrings include duplication of the aortic arch due to
persistenceof both the right and left fourth arches (Fjg. 27-27)
and aberrant right subclavianartery (Fig.27-28). A double aortic
arch traps the esophagusbetween the archesand the heart base.
Occasionally,the trachea may also be constricted, resulting in
dyspnea.An aberrant right subclavianartery with a normal aorta
traps the esophagusbelow the artery. The artery, normally
branching rightward off the brachycephalictrunk, may arise di-
rectly from the aorta just distal to the left subclavian artery; it
then crossesretroesophageally from left to right, constricting the
esophagusdorsally.If a well-definednormal left descendingaortic
margin is visible on the ventrodorsal/dorsoventral thoracic radio-
graph, one of the lesscommon vascularrinq anomaliesshould be
consideredas the cause.Ultrasound examination or angiography
is needed to characterizethese anomalies.Frequently,additional
cardiac or vascularanomalies(such as persistentleft cranial vena
cava)are presentbut may not be of physiologicsignificance.Rarely,

iiilllll:i1119lll:

iiitlllli:i118lll
;ll'-l@tr,rt$
:rrfrfrut:1tftrl
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Figure 27-26. Lateralview of the cranialthorax of a young cat 1.

wi t h a p e r s i s t e nrti g h t- fo u r th
a o r tica r ch .T h e r eis fo o d a ccu m ul ati on .":
ln i h e d i l a t e ds e g m e n to f th e e so p h a g u scr a n iato l th e o b str uctl on.
The tracheadeviatesventrally.(Courtesyof New YorkState College
of V e t e r l n a rMy e d i c i n elth
, a ca NY),
3 42 NE CKA ND T H O R AX -C OMP AN IO A
NN IMA LS
1_--,- E
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;
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
with persistentright aortic arch, the ductus arteriosusmay remain
patent and can be auscultatedby its characteristicmachinery or
continuous murmur. Occasionally,a vascularring anomaly may be
accompaniedby generalizedmegaesophagus(see Fig. 27-13),
which may worsen the prognosis for responseto therapy. For
this reason, contrast examination is recommendedfor complete
evaluationof vascularring anomaliesprior to surgicalcorrection.
Redundant esophagus. Esophagealredundancy is an occa-
sional incidental finding; it may be problematicin young brachyce-
phalic breeds,especiallyEnglish bulldogs and Shar peis. Regional
dilation may be presentat the site of deviation in the thoracic inlet
(Fig. 27-29). In survey radiographs, focal gas accumulation may
occur in the cervicaland cranial thoracic esophagus,or the radio-
graphs may be normal. Contrast examinationhighlights a tortuous
path, usually at or just caudal to the thoracic inlet. Ventral devia-
tion is usually present in redundancy,but occasionally,the lateral
view appearsnormal and leftward or rightward lateral deviation is
seenon a ventrodorsalor dorsoventralview; therefore,orthogonal
views are recommendedwhen this problem is suspected.If the
radiograph is exposedin the midst of bolus transport, the peristal-
tic contraction of the esophagusmay mask the redundancyor may
mimic a focal diverticulunr.
Generalized megaesophagus
Both congenitaland acquiredmegaesophagus occur in the cat and
dog. The congenital form may be hereditary in both the dog
(miniature Schnauzerand Fox terrier breeds) and the cat. The
underlying causeof acquired megaesophagus is often unidentified
(idiopathic), although it may be secondaryto one of many possible
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,/,
I
N.r'
ic C rV C ,crani alvena c av a;C V C ,
artery.
causes,including chest trauma, tetanus,organophosphatetoxicity,
lead toxicity, myasthenia gravis, polymyositis/polymyopathy, auto-
immune disease(systemiclupus erythematosus),hypoadrenocorti-
cism, dermatomyositis,thymoma, dysautonomia(cats),gastrointes-
tinal disease(gastric dilation/volvulus,pyloric obstruction, hiatal
hernia, esophagitis),central nervoussystem(CNS) disease(menin-
gitis, neoplasia,CNS trauma), dyspneausually due to upper airway
obstruction, and possiblyhypothyroidism.A defect in the afferent
innervation may be presentin both congenitaland acquiredforms
of idiopathic megaesophagus.
Generalizedmegaesophagus with a gas-filledlumen may be visu-
alized along all or part of its length on survey radiographs.In the
lateral view, the cervicalportion is apparentbeginning just caudal
to the cranial esophageal sphincter.\Ahen mildly dilated,the esoph-
agus is visible dorsal to the proximal trachea,crossingsomewhat
lateral to the tracheaat the thoracic inlet. As it dilatesfarther, the
esophagusdrapes around the trachea and depressesit ventrally
(Fig. 27-30).If the esophagusis fluid-filled, the lumen may not be
visible becauseof silhouetting of the soft tissue and fluid (Fig.
27*3lA). The thoracic esophagus,when gas-filled,may be inadver-
tently overlookedbecauseof the relativeradiolucencyof the adja-
cent lung field. Close scrutiny, however, provides several hallmark
findings characteristicof its presence.
\{hen the cranial thoracic esophagusdilates, the dorsal wall
abuts the paired longus colli muscles,which may be seenas a sharp
interfacefrom the thoracic inlet to the ventral asoectof T5 or T6.
The ventral wall projects lateral and often ventril to the trachea.
The draping of the ventral wall over the dorsal trachealwall results
in summation (silhouetting) of the two walls, which createsthe
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

Figure 27-29, The cranialthoracic esophagusin this immature

b u l l d o gi s r e d u n d an t.T h e to r tu o u sp a th m a y h a m p e r p e ri stal si s.
(Courtesyof New York State Collegeof VeterinaryMedicine,lthaca,
NY)

,l.,.ll..'ll.llll
'' il
l

llr .

I
f'
d

l.'t. ''
fr
N:
11; Figurc 27-30. Lateralview of the thoraxof an agedcat with chronic
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
i nterfacebetw eenthe l onguscol l imuscl esand the es ophageal l umen
/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 )

lllr.
*'lllll

;aa',,.
au:i'riiiil
itt4ll:
r
t:,,ril*ll

il
,i
ll]]-i111
::f:):',';
tin
i9

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
Figure 27-32. Dorsoventralviewof the thoraxof an adultdogwith mega-
esophagus.Thelateral
wallsof the esophagus areseenas thin,softtissue
to the spine(arrows).
bandsroughlyparallel Theyconverge in the caudal
(Courtesy
thorax. of NewYorkStateColegeof VeternaryMedicine, lthaca,
NY)
tracheal band or tracheal stripe sign. When gas-distended,the
caudal thoracic esophagusis seen as a pair of thin, soft-tissue
stripes that converge to a point overlying the diaphragm and
cranial abdomen. Absenceof the ventral stripe may result from
overlap of the caudal vena cava (see Fig. 27-30). On the dorsoven-
tral or ventrodorsalview, the dilated, gas-filledcervical esophagus
may be hidden by the spine and trachea,although displacementof
the tracheato the right may be seen(seeFig.27-31.8).The dilated
cranial thoracic esophagusproduces a wide cranial mediastinum
that is relativelyradiolucent. The lateral rnargins are indented on
the left by the descending aorta and on the right by the azygous
vein. The caudalthoracic esophagusconvergesto a V at the hiatus
of the diaphragm (Fig. 27-32).
When the esophagusis not identified on survey radiographs,
contrast radiographsare required.A barium contrast examination
also better defines the degree of esophagealdilation, the iack of
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
would causeirregular or asymmetricalnarrowing (seeFig. 27-22).
When the contrast medium fails to enter the stomach on routine
swallows, confirmation of caudal esophagealpatency can often be
made by elevating the forequarters and inducing an additional
swallow, which usually stimulates relaxation through initiation of
the oropharyngealphase.Mild or intermittent motor disturbances
of the esophagusmay not be identified by standard radiography.
Early or segmentaldiseaserequiresdynamic evaluationby fluoros-
copy. Differences in esophagealresponseto liquids and solids may
also be assessed.
I Esophageal perforation and
I esophageal fistulas
Cervical esophagealperforationsresult in leakageof luminal con-
tents into the loose periesophagealfascia,leading to chemical irrita-
tion with sepsisand secondaryinflammation. Gradually,an abscess
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-
cheal, esophagobronchial,or esophagopulmonaryin nature. For-
eign bodies have been recognizedas a causeof fistula, which can
be induced by graduallocal esophageal necrosisleadingto perfora-
tion and by adhesion formation between the esophagusand the
adjacentrespiratory tract tissue. Potential etiologiesmay also in-
clude malignant esophagealdisease,penetrating trauma to the
esophagus,infectious or neoplasticpulmonary disease,preexisting
esophagealdiverticula, and periesophageal lymphadenopathy. In
survey radiographs,bronchopneumoniamay be noted. The loca-
tion of the pulmonary infiltrate is dependenton the site of commu-
nication, which may vary according to whether the speciesaffected
is feline (caudal segmentof the left cranial lobe) or canine (right
middle lobe). If there is a history of coughing and choking, which
are exacerbatedby ingestion of fluids, a barium contrast swallow
is indicatedto locatethe fistula (Fig. 27-33).If pleural involvement
is noted on the survey radiographs,an isosmotic organic iodide
compound is recommendedfor the esophagramto minimize possi-
ble contaminationof the pleural spaceby barium. An ionic organic
iodide contrast medium may induce pulmonary edemaif commu-
nication with the lung parenchymais present.Esophagealfistulas
should not be mistaken for inadvertentaspiration and subseouent
alveolarization of contrastmedium durins a routine swallow.
I Diseasesof the hiatus
The esophagusis tethered to the hiatus of the diaphragm by a
phrenoesophagealmembrane that normally allows only minor cra-
nial movement of the abdominal segment.A congenitalor acquired
abnormality of the hiatus may allow for reduced caudal esophageal
sphincter tone and reflux, resulting in the development of a sliding
hiatal hernia, a periesophageal hiatal hernia, a diaphragmaticher-
nia, or a gastroesophageal intussusception(see Chapter 29). The
differentiation of these disorders may be difficult owing to the
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
that appearscontinuous with the diaphragm. The cranial thoracic
esophagusmay be partly or completely dilated and gas-filled cranial
to the mass.Sizeand visibility of the fundic gasbubble are variable,
but it is often small or not seenat all with herniation and intussus-
ception. A barium contrast study is required to locate the gastro-
esophageal junction and the gastricfundus.
 The Esophagus 345

Figure 27-33. Lateralesophagramof a young dog.Thereis srmulta-

n e o u s f i l l i n go f t h e r ig h t ca u d a llo b e b r o n ch u sa n d th e e s ophagus,
e a l la (. F r o mEttin g eSJ
in d i c a t i nag b r o n c h o e so p h a g fistu r ( e d ) Textbook
:
o f V e t e r i n a r yI n t e r na M
l e d icin e 2, n d e d . Ph ila d e lp h iaWB, Saunders,
1983.)

Gastroesophageal reflux
Reflux esophagitisoccurs when acidic gastric contents remain
within the esophageallumen for a prolonged period, resulting in
mural inflammation. Reflux may be a normal consequenceof
swallowing, but the retrograde flow of gastric acid should be
rapidly clearedby the esophagusby either primary or secondary
peristaltic contractions. Diagnosis of clinically significant gastro-
esophagealreflux may be difficult using survey radiography. Survey
radiographs may be negative or may show an esophagealopacity
that varies from subtle in the caudal mediastinum, to visible owing
to luminal fluid retention. to dilated and air- or fluid-filled when
the esophagitisis extensive(seeFig. 27-24). Most often, the survey
findings are negative or minimal, and they may be overlooked.
Contrast examination with static imaging may also be negative. If
esophagitisis severe,retention of contrastmedium with esophageal
mucosalirregularity or ulceration,as well as thickening or diffuse,
nonuniform dilation may be seen (Fig. 27-34). Infiltration by
inflammatory or granulation tissue usually distorts the mucosal
surface,obliterating the longitudinal or oblique folds. Most often,
during a gastrointestinalcontrast examination,intermittent reflux
is seenas recurrenceof the appearanceof contrast medium within
the caudal esophagusas barium gradually transits the stomach.
Fluoroscopy and nuclear scintigraphy are more accurate means of
diagnosinggastroesophageal reflux.
Hiatal hernias
With hiatal herniation, the caudalesophagealsphincter,recognized
as a focal narrowing of the barium contrast column, is cranially
displaced,with no identifiableabdominal esophagealsegment.
Variable amounts of rugae-lined gastric fundus are seen as an
extension of the caudal esophagusin the thoracic cavity (Fig.
27-35). A periesophagealhernia causespartial obstruction and
displacementof the terminal esophaguslaterally away from the
herniatedgastricfundus. On the ventrodorsalor dorsoventralcon-
trast radiograph,the gastricrugaeare seenlateralto the esophagus
within the caudalmediastinum.
Gastroesophageal intussusception
Gastroesophageal intussusceptionis a rare condition of young
puppies in which the stomach invaginatesinto the caudal esopha-
geal lumen and may be accompaniedby other abdominal viscera
(spleen,duodenum, pancreas,and omentum). Pre-existingcongen-

t iilllllt',
illlll.iliil

Figure 27-34. Gastroesophageal reflux is characterizedby con- ...tugtr,jui@

q-B
t r a s t m e d i u m i n t h e ca u d a le so p h a g u sa fte r cle a r in go f th i s area
s u b s e q u e n t o t h e in itia la d m in istr a tioonf co n tr a stm e d iu m.The '::a,-))):all
:a::)).
,,-,,ttr!rl,,,tlll1,
ventra wall of the esophagusin this dog is thickened (arrows)by it:ut.i:l
ttrr,,ru,
c h r o n i ci n f l a m m a t i onwh
, ich im p a ir sr a p idcle a r in ga n d fu r th ercom-
poundsthe problem.(Courtesyof New York State Collegeof Veteri- i,ttlll
'1,,,,t;lu
n a r yM e d i c i n e l,t h a c a NY)
,
346 AN IM A LS
NE CKA ND T H O R AX -C OMP AN IO N

Figure 27-35. A hiatalherniais present.Esophagitisand caudalesophagealdilationresult

trom the gastroesophagealrefl ux.The caudalesophageal sphi ncter(arrow )i sw el l defi nedc rani al
to the di aphragm.(C ourtesyof N ew Y ork S tate C ol l egeof V eteri naryMed i c i ne,l thac a,N Y )

ital or idiopathic megaesophagusmay be present. With extensive
hernias,a large soft-tissueor heterogeneousmass may develop in
the caudal mediastinum (Fig. 27-36). A gas-filled,dilated esopha-
gus may or may not abut the mass.Rugal folds are often recognized
covering the mass; a stomach silhouette may be absent from the
cranial abdomen, or when gas-distended,the stomach lumen may
present with a defined communication with the caudal mediastinal
mass.Contrast examinationin thesepatientsconfirms obstruction
of the caudal esophagus by the mass with failure of contrast
medium to fill the abdominal gastric lumen. Occasionally,gastro-
esophagealintussusception may be recognized as an intermittent
problem, and only minor invagination occurs (Fig. 27-37).
In summary, esophagealdiseasemay be characterizedby focal
or diffuse involvement. Diffuse diseaseusually results in megaeso-
phaguscharacterizedby generalizeddysfunction,but megaesopha-
gus may also occur with obstruction of the terminal esophagus
from a few focal causes.Alternatively, focal or segmental disease
may havenumerouscauses.The common locationsof various focal
esophageallesions are listed in Table 27-3. The absenceof abnor-
mal esophagealradiographic findings does not preclude the pres-
ence of esophagealdisease;such findings are often encountered
with acute esophagealdisease.In addition, the presenceof indirect
signsof esophagealdiseaseshould be anticipated.Focal or general-
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

&

Figure 2736, Lateralview of the caudodorsal

thoraxof a mature
dog with a gastroesophageal intussusception.
The radiopacityof the
gastri ccontentsmay be seen i n the caudalthoraxs uperi mpos ed
over the left diaphragmaticcrus and dorsocaudalung fieid (arrows).
(Courtesyof New York State Collegeof VeterinaryMedicine,lthaca,
\Y )
 The Esophagus 347

Figure 27-37. Gastroesophageal intussusceptlonand related ob-

s a y b e in te r m itte not r p e r siste n The
s t r u c t i o no f t h e e s o p h a g um t. si gns
o f r e g u r g i t a t i oann d vo m itin gwe r e sp o r a d icin th is ca t. Ga stri crugal
folds, covered with barium (arrows),project rnto the dilated caudal
esophagus.(Courtesyof New York State Colege of Veterinarylvledi-
c i n e ,l t h a c a N , Y)

Table 27-3. Gharacteristic site of focal esophageal disease

Cervical region Cranialthoracic region Caudal thoracic region
Ach ala sia Vas c ularr ing a n o m a l y Esophagitis(reflux)(patulentcaudal esophageal
sphincter)
Asynchrony Esophagitis(reflux) Foreignbody
Ch ala sia Stricture Perforation
Fo reig nbo dy Per ies opha g e aml a s s Leiomyoma
Esophagitis(caustic) Redundanc y Gastroesophageal intussusception
Extensionof neoplasia Diverticula H i a t a lh e r n i a
Perforation Foreignbody Esophagealfistula
Segmentalhypomotility Neoplas ia
Perforation
348 NE CKA N D T H OR AX -C OMP AN IO A
NN IMA LS

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
selected examinations of the abdomen and thorax. Vet Clin North Am Small Anim
Pract 30:349,2000.
3. Kealy JK: The abdomen. In Diagnostic Radiology of the Dog and Cat, 2nd ed.
Philadelphia,WB Saunders,1987,p 41.
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. Watrous BJ; Clinical presentation and diagnosis of dysphagia. Vet Clin North Am
Small Anim Pract 13:437,1983.
6. Watrous BJ: Esophagealdisease.In Ettinger Sf (ed): Textbook ofVeterinary Internal
Medicine: Diseasesofthe Dog and Cat. Philadelphia,WB Saunders,1983,p 1191.
7. JonesBD, JergensAE, Guilford WG; Diseaseof the esophagus.In Ettinger SJ (ed):
Textbook of Veterinary lnternal Medicine: Diseases of the Dog and Cat, 3rd ed
Philadelphia,WB Saunders,1989
ru Ouestions
l. Increasedradiopacity associatedwith the esophagusmay be
due to:
4, This surveyradiographicexaminationis of a 10-year-oldneut-
ered male domestic shorthaired cat (Fig. 27-38). he was presented
for sudden onset of dyspnea.What radiographicsigns are present?
What are the radiographicconclusions?What may causethe com-
bined radiographicfindings?
5. Dilation of the esophagusmay cause:
A. leftward and ventral deviation of the intrathoracic trachea.
B. leftward and dorsal deviation of the intrathoracic trachea.
C. rightward and ventral deviation of the intrathoracic tra-
cnea.
D. rightward and dorsal deviation of the intrathoracictrachea.
6. Focaldilation of the esophagusjust cranial to the heart baseis
often seenwith vascularring anomalies.Name another esophageal
diseasethat may appearsimilar to vascularring anomalies.
A. nonradiopaqueforeign body lodged at the heart base
B. esophagealstricture locatedat the heart base
C. esophagitis

rfiiiisli:

llllrt,
ilil
,,,lll!lll
.ibrllllii;ur9ll
r:,r'tltiill

Figure 27-38
 The ThoracicWall 349

\t:L)

Figure 27-39
,,]',iii]lr,,:lii
riiiiutr-
' tlirutl

D. esophagealredundancy A. aorta and spine

E. all of the above
7. If you suspectesophagealmucosaldisease,which contrast me-
dium would be indicated to demonstratethis?
A. liquid barium sulfatesuspension
B. barium sulfatepaste
C. ionic organic iodide contrast medium for oral administra-
tlon
D. nonionic isosmolar organic iodide contrast medium for
oral administration
B. cranial vena cavaand spine
C. spineand azygousvein
D. aorta and azygousvein
9. A 4-year-old neutered female mixed-breed dog presentedfor
intractablevomiting and gagging.In survey thoracic radiographs,
there was a large heterogeneousmass located in the caudal right
thoracic region. A barium swallow was performed using liquid
barium sulfatesuspension(Fig. 27-39). \Mhat is your list of radio-
graphic differentialdiagnoses,in decreasingorder of likelihood?

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
(or the sternum ventrally), intercostalmuscles,the parietal pleura,
and the associated vasculatureand nerves.Thoracic wall abnormal-
ities are often overiooked when radiographs of the thorax are
interpreted. Findings involving the thoracic wall are often critical
in making the correct diagnosis, or in deciding what the next step
in patient evaluationshould be.
Normal radiographic
Ir appearance
Other than increasedopacity causedby its osseouscomponents
(i.e.,ribs, sternebrae),the appearanceof the thoracic wall is homo-
geneous.In ventrodorsal (VD) or dorsoventral (DV) views, ribs
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

Fi gure2S -1. D orsoventral thoraci cradi ographofadog.Theri ghtthoraci cwal l

i s normal .Trac e
a rib from its vertebra.The rib coursescaudolaterally to its most lateralextent,then appearsto
coursecaudomedi al lOn y. the l eft thoraci cw al l i s di ffusesw el l i ngcausedby sub c utaneous fl ui d
From thl s radi ograph,
admi ni strati on. i t i s i mpossi bl eto tel l the exact causeo f thi s s w el i ng;
hemorrhage or a tumor coul dal soresul ti n thi s appearance.

their most lateral extent,then continue caudomedially(Fig. 28-1).
In lateral views, ribs course ventrally or caudoventrally from their
vertebralorigins.At the costochondraljunction, the costalcartilage,
which may be mineralized, typically changesdirection and courses
cranioventrally (Fig. 28-2).
Mineralization of costal cartilagesis common (see Fig. 2B-2);
this mineralization may occur normally in young dogs. However,
nearly all old dogs have mineralization of costal cartilages.Move-
ment at the costochondralor costosternaljunction, which has been
stiffened by costal cartilage mineralization, usually results in an
increasedsize of the junction with exuberant adjacent calcification
(Fig. 28-3). The opacities createdby normal or enlarged costo-
chondral mineralization may be confused with lung nodules in VD
or DV radiographs(Fig. 2B-4). Costochondralmineralizationmay
also be confused with more aggressiveprocessessuch as infection
or tumors, especiallywhen the calcification is extensive.
Pedunculatedthoracic wall soft-tissuenodules, such as nipples,
papillomas,or ticks, produce a distinct, well-marginatedopacity in
the radiograph (Fig. 28-5). This opacity is very distinct because
of the sharp contrast provided by the surrounding air and the
perpendicularrelationshipbetweenthe nodule and the x-ray beam.
When a suspectednodule is seen in VD or DV radiographsin a
location consistentwith a nipple, careful examination of the patient
usually clarifies the significance of the finding. If necessary,posi-
tive-contrastmedium can be placed on the nipple and the radio-
graph repeated(Fig. 28-6).

Figure 28-2. Left lateralthoracicradiographof a normaldog. Note

the arrangement of the ri bs.Fromthe vertebralattachment, ri bsc ours e
ventrallyor, as in this dog, caudoventrally. At the costochondrajunc-
ti on,the costalcarti l agechangesdi recti onand coursesc rani ov entral l y .
ln this dog, there is stippledmineralization (arrowheads) of the costal
Thi si s a normalfi ndi ng,andcan be seeni n veryy oungdogs .
cartl l ages.
 The ThoracicWall 351

Figure 28-3. Lateralradiographof a normal9-year-old dog. Note

t h e i r r e g u l a cr a l c i f i ca tioant th e co sto ch o n d r ajul n ctio n .T h is i s a
n o r m a lf i n d i n gi n o l d e r a n im a ls.T h e e xa ct m e ch a n ismfo r these
ca l c i f i c a t i o ni s u n k n o wn ,b u t co n sta n tm o tio n in a n a r ticul aton
t h a t i s b e c o r r i n gs t i f 'wir h a g e is o r e p o ssib leca u se .

I Gongenital abnormalities A congenital malformation of the sternum consisting of dorsal

displacement of the caudal sternal segmentsis occasionallyseen in
Normally, there are 13 pairs of ribs. Agenesisor hypoplasia of the
cats, and rarely in dogs. This malformation is termed pectus exca-
13th rib is common. This anomaly can be either bilateral or
vatum (Fig. 28-8). The degreeof sternal displacementvaries,but
unilateral. Uniiateral agenesisor hypoplasia is especiallyimportant
it may be so severethat the xiphoid actually contacts the ventral
to recognize when the site of a herniated intervertebral disc is
aspect of the vertebral column. It is important to realize that the
being identified by palpation of the last rib in preparation for spinal
heart will be displaced to either the right or the left as a result of
decompressivesurgery. If the rib asymmetry is not recognized,the
dorsal sternal displacement.
surgeon may operate at the wrong site if the ribs are used as
Fewer numbers of sternebrae than normal have been reported
landmarks (Fig. 28-7).
in animals with congenital peritoneopericardial diaphragmatic her-
nia.l This reduction in sternal number in essencecreates a short
sternum; this may result in contact between, and silhouetting of,
the borders of the heart and diaphragm in the area of contact.2

I Thoracic wall trauma

Thoracic wall trauma, common in small animals, often results in
fracture of the rib (Figs. 28-9 and 28-10). Displacementof the
fracture ends may be varied in extent. Minimally displacedfractures
are easily overlooked. Internal or external fixation of rib fractures
is rarely necessaryas they heal spontaneously.
Becauseof movement, healing rib fractures may be characterized
by lucency at the fracture site and by adjacent periosteal prolifera-
tion (Fig. 28-11). The appearanceof a healing rib fracture may be
similar to that of a rib tumor or rib infection. A history of trauma,
or the involvement of multiple adjacent ribs, provides a stronger
basis for consideration of trauma. In reality, distinguishing healing
fractures from neoplasia or infection on a radiographic basis is
impossible. If an aspirateor biopsy is not desirable,or if it provides
nonspecific results, repeat radiographs in 2 to 3 weeksare required.
When healing is complete, or nearly complete, lysis subsides and
rib margins becomesmooth (Fig. 28-12).

I Rib tumors and infection

A thoracic wall mass, whether the result of trauma, infection, or
neoplasia,may create an extrapleural sign.1a This extrapleural sign
results from medial extension of a mass from the thoracic wall,
causing an intrathoracic mass effect and broadly based medial
displacement of the parietal pleura. This pleural displacement also
results in displacement of adjacent lung. This mass, along with the
resultant lung displacement, is called the extrapleural sign (Figs.
28-13 and 28-14). One can think of the parietal pleura as being
"stuck" to the thoracic wall and the expanding mass as pushing
Figure 284- Ventrodorsalradiographof a normal cat. There is a circular
medially against it. The adherence of the pleura to the thoracic
o p a c i t yt h a t c o u i db e co n fu se dwith a lu n g n o d u le .In th is cat, thi s opaci tyi s
a n e n d - o nv i e w o f a co sto ch o n d r a jul n ctio nAb
. se n ceo f th is opaci tyi n ei ther wall affords resistanceto medial extension, thus creating a broad-
la t e r avl i e w w a s a c l u eth a t its o r ig lnwa s n o t th e lu n g . based concavejunction between the mass and the thoracic wall as
Text continueson page 357
352 ANIN/IALS
NECKAND THORAX-CON/IPANION

Figure 28-5. Left lateralthoracic radiographof a dog with a nipple /affod

superi mposed over the caudoventral
thorax.S i mi l arfocal opac i ti esc oul d be
producedby engorgedti cks,or peduncul ated
tumors.S ee Fi gure5-15 for more
i nformati on,

Figure 28-6. Ventrodorsal radiographs of a dog. A, Thereis an obviouscircular

opa c i t yt h a t h a s t h e a p p e a r a n ceo f a lu n g n o d u le .T h e d o g w as exami ned
c lin i c a l l ya,n d a l a r g en i p p lewa s fo u n d . Ba r iu mwa s p la ce do n the ni ppl e,and
the radiographwas repeated /B/. The barium correspondsto the opacityand
c on f i r m si t s i d e n t i t ya s a n ip p le ,

Figure 28-7. Ventrodorsalspinalradiographof a dog. The right

13th ri b i s absent.A symmetri cri bs can resul t i n s pi naldec om-
pressivesurgerybeing performedat the incorrectlocationunless
the asymmetryis recognizedpriorto surgery.Unilateralrib agenesrs
i s very commoni n dogs.
 The ThoracicWall 353

"l,ll,l.rr]llrl

Figure 28-8. Left lateral1Aland dorsoventral/8/ thoracicradiographsof a cat

w i t h p e c t use xca va tu mT. h e h e a r tis d isp la ce dto the l eft by the sternalmal posi - rl',i,rriill
t i o n i n gT e ig h t)in th is ca t i s normaL.
. he n u m b e ro f ste r n e b r a ie 1r{ llr'l,
,:
tlu)'t)r::,
:ttl:'.

)
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

irlll .illilll iil

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 .

Figure 28-13. Dorsoventralthoracicradiographof a dog with an extrapleuralhematoma '.:t1l))a

"i
t',i.i:)

:|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 .

ihe mass slowly advancesmedially. The extrapleural sign is best
seenwhen the primary beam strikes the lesion tangentially. Visual-
ization of the extrapleural sign may require supplemental oblique
projections.
The extrapleural sign can be used to discriminate between lung
and thoracic wall as the origin of a peripheral intrathoracic mass.
If a peripheral lung mass contactsthe thoracic wall, the junction
between the mass and the thoracic wall forms an angle equal to or
less than 90 degrees (Fig. 28-15). On the other hand, if the
peripheral opacity is due to a thoracic wall mass extendingmedi-
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
infection following trauma or surgery is also very rare. Systemic
mycosesmay result in rib lesions as a result of hematogenous
spread(Fig.28-16). Mycotic rib osteomyelitisresultsin an aggres-
sive rib lesion, which may be primarily lytic, primarily productive,
or mixed. Biopsy is necessaryto differentiatethe lesion from neo-
plasia.
Primary and secondaryrib tumors are more common than rib
infections. Most primary rib tumors are mesenchymaltumors
(e.g.,chondrosarcoma,osteosarcoma). Primary rib tumors enlarge
primarily intrathoracically; as a result, they are often very advanced
at the time of diagnosis.Extensivepleural effusion often accompan-
ies primary rib tumors; when present,this effusion makes radio-
graphic detection and evaluation of the rib lesion difficult (Fig.
28-17). Rib tumors may be primarily lytic or primarily sclerotic,
or they may contain a mixture of lysis and sclerosis.Lytic changes
are typically more common than scleroticchanges(Fig. 28-lB).
As cancer patients are being treated more aggressiveiy,metastasis
of solid tumors to the skeleton is being diagnosed more frequently.
Figure 28-16, Dorsoventral/A/and right lated (B)thoracicradiographs
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
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.
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
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
The ThoracicWall 357
The ribs are one of the more common sites in the skeleton to
which solid tumors, especiallyepithelial tumors such as mammary
and prostatic adenocarcinomas, metastasize.Metastaticrib lesions
are aggressiveand are typically lytic, but productive lesions may
also be present. The subtle lytic nature of rib metastasesmakes
their radiographic detection difficult, and they are often over-
Iooked. Rib metastasessecondaryto a solid tumor usually arise
hematogenously,but local extension of a tumor into an adjacent
rib, as from a mediastinaltumor, may alsobe observed(Fig. 28-19;
seealsoFig. 28-18).
I Sternal tumors and infection
Primary sternal tumors are uncommon. Mesenchymaltumors of
the sternebraedo occur and they result in aggressivelesions of the
sternebrae.Some malignancies within the peritoneal cavity, such as
pancreatic adenocarcinoma, may extend along lymphatic channels
into the ventral mediastinum and eventually invade the sternum.
Aggressivemammary neoplasmsmay also result in sternal invasion.
In thesepatients,there is usually voluminous pleural effusion and
a soft-tissue mass effect adjacent to the sternum (see Fig. 28-20).
Primary pleural tumors, for example,mesotheliomas,are rare and
typically do not result in associatedbone changesin the ribs
or sternum.5
Sternal infection may result from external trauma, such as a bite
wound, or it may occur hematogenously.Hematogenousinfection
may lodge in the intersternal space,resulting in signs similar to
those of discospondylitiswith lysis of sternebralend plates,widen-
ing of the intersternal space,and aggressivelytic or productive
bone changeswithin the sternebrae.
of a dog wlth two rib lesions(arrows).Eachlesionhas resultedin expansionof the rib,
of the l esi onsi s too aggr es s i vto
e be due to
s, theseri b es i onsw ere tl .e
and
of D epartmentof V ete ri nary Medc ne a.c
, 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

Figure 28-19. Lateralradiographof a cat with advancedmammary

adenocarci noma.
peri osteal
The tumor has i nfi l tratedthe sternum.c aus i ngac ti v e i
$
reacti on.S ternali nfecti oncoul dal socausethi s radi ographi c
appearance, but w i th the underl yi ng mammarytumot neopl as ti icnfi l -
trationof the sternumis more likelv.
 The Diaphragm 359

Figure 28-2O. Left lateralthoracicradiographof a dog with drain-

ing soft-tissueswellingat the ventralaspectof the midportionof the
s t e r n u m .L i s tt h e m ajo rr a d io g r a p hsig
ic n s.

References A. Lower the kVp and compensatorily raise the mAs.

B. Raise the kVp and compensatorily lower the mAs.
l. Evans SK, Biery DN: Congenital peritoneopericardial diaphragmatic hernia in C. Raiseboth the kVp and mAs.
the dog and cat: A literature review and 17 additional case histories. Vet Radiol D. Lower both the kVp and mAs.
2 l :1 0 8 ,1 9 8 0 . E. Increasethe focal spot-film distance.
2. Berry CR, Koblik PD, Ticer JW: Dorsal peritoneopericardial mesothelial remnant
as an aid to the diagnosis of feline congenital peritoneopericardial diaphragmatic 2. Which of the following may be expectedto produce the "extra-
hernia. Vet Radiol 31:239,1990. pleural sign"?
3. Myer W: Radiography review: The extrapleural space.J Am Vet Radiol Soc 14:157, A. Intercostal mass
r978. B. Parietal pleural mass
4. Lord PR Suter PR Chan KF, et al: Pleural, extrapleural, and pulmonary lesions in C. Expansile rib lesion
small animals: A radiographic approach to differential diagnosis. J Am Vet Radiol Soc D. Fracturedrib
I3:4, 1972. E. Subcutaneousabscess
5. Thrall DE, Goldschmidt MH: Mesothelioma in the dog: Six case reports. I Am Vet
Radiol Soc l9tl07, 1978. 3. True or False. Stippled mineralization of costal cartilages is an
abnormal aging change and is not seenvery often.

I Ouestions 4. Provide image interpretation for Figure 28-20, a left lateral

l. Ifproperly positionedand exposedroutine thoracic radiographs
fail to produce sufficient contrast for accurate interpretation of
suspectedchest wall lesions, the following change(s) in radio-
graphic technique for supplemental examination may be helpful:
thoracic radiograph of a dog with draining soft-tissue swelling at
the ventral aspectof the midportion of the sternum. List the major
radiographicsigns.
Answers begin on page727,

CHA P TE R

29
The Diaphragm
r Richard D. Park

The diaphragm is the muscuiocutaneous partition between the
thoracic and abdominal cavities. Embryologically, the diaphragm
is formed by the septum transversum ventrally and by the mesen-
tery of the foregut and two pleuroperitoneal folds dorsally.
The diaphragm provides approximately 50o/oof the mechanical
respiratory force required for inspiration.t The diaphragm also acts
as a mechanical partition between the thorax and the abdomen.
Lymph vesselsfrom the abdomen penetrate the diaphragm and
drain into the thoracic lyrnph nodes and vessels.Thus, inflamma-
torv or neoplastic abdominal diseasemav spread to the mediasti-
num and pleural space.Lymph flow from the thorax to the abdo-
men does not occur.2
The diaphragm consists of a tendinous center and three thin
peripheral muscles: the pars lumbalis, the pars costalis, and the
pars sternalis.The pars lumbalis consistsofthe right and left crura,
which attach to the cranial ventral border of L4 and the body of
L3. This attachment results in these vertebrae occasionally having
a concaveindistinct ventral margin that may be mistaken for bone
lysis. The pars costalis attachesin an oblique direction to the 13th
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

cartilage.3The diaphragm is convex and extends into the thorax

from its attachments. In doing so, the phrenicocostalisand phreni-
columbalis recessesare created.
There are three openings through the diaphragm: (1) the dorsally
located aortic hiatus enclosesthe aorta, azygos veins, and hemi-
azygosveins, and the lumbar cistern of the thoracic duct; (2) the
centrally located esophageal hiatus encloses the esophagus and
vagus nerve trunks; and (3) the caudal vena cavaforamen is located
at the junction of the muscular and tendinous portions of the
diaphragm.

I Normal radiographic anatomy

Radiographically, only a small portion of the diaphragm can be
seen on any one view. It appears as a thin, convex structure of
soft-tissue opacity extending in a cranial and ventral direction.
Radiographicvisualizationofthe diaphragm is dependenton adja-
cent structures being of different opacity. Most of the thoracic
surface is visible becauseof the adjacent gas-filled lungs. Parts of
the thoracic surface are not visualized where the lungs are not
in contact with the diaphragm, that is, the phrenicocostalis and
phrenicolumbalis recesses.A large portion of the abdominal dia-
phragmatic surface is not seen because it silhouettes with the
adjacent liver. The ventral abdominal diaphragmatic surface is
visible on the lateral view when fat is present within the falciform
ligament. The dorsal aspectof the left diaphragmatic crus and the
gastric wall appear as one linear structure when gas is present in
the gastriccardia.
Diaphragmatic structures that may be distinctly visualized radio-
graphically are the right and left crura, the intercrural cleft, and
the cupula (body) (Figs.29-l to 29-4). Associatedstructuresthat Figure 29-2. Rightlateralrecumbent
viewof the diaphragmatic
regionof a
may also be seen are the caudal vena cava and the caudal ventral normaroog.
mediastinum. On the lateral view, the right crus of the diaphragm
blends with the caudal vena caval border, and the gastric fundus
may be seen adjacent to the abdominal surface of the left crus. The
intercrural cleft is a shorter, convex, opaque line caudal and ventral the dorsoventral or ventrodorsal views. Also, on these views, the
to the crura (see Figs. 29-l and 29-2). The cupula is the most thoracic surface of the diaphragm may be visualized as one, two,
craniai conVex portion of the diaphragm on both the lateral and or three convex projections into the thoracic cavity (see Figs. 29-3
and.29-4).
Severalnormal variations of diaphragmaticposition and shape
may be seen radiographicaliy. Factors that cause this variable ap-
pearanceare both real and apparent. Real factors consist of breed,
age, obesity, respiration, and gravity. Apparent factors are x-ray

Figure 29-1. Left lateralrecumbentradiographof the diaphragmatic

region Figure 2Sr-3. Ventrodorsai view of the diaphragmatic regionof a normaldog
of a no r m a ld o g . with the cupulaand both cruraprojectinginto the thorax.
 The D iaphr agm 361

The radiographic appearanceof the diaphragm in ventrodorsal

Figure 294, Dorsoventral regionof a normal
view of the diaphragmatic
shapeprojecting
dogwithonlyoneconvex intothethorax.
beam centeringand animal positioning during radiographicexami-
nation. When all permutations of these variablesare considered,
more than 51,000 combinations are possible.'Obviously, most of
these variables are not radiographically significant; however, some
must be recognizedand understood.Changesthat are most appar-
ent radiographicallyare the position, shape,and visualization of
the cupula and crura. The relative position of the crura is most
dependenton position and size of the animal and primary x-ray
beam centering.
The most dependent crus is usually displaced cranially when an
animal is in lateral recumbency. In right lateral recumbency, the
crura appear to be parallel (see Fig. 29-2); in left lateral recum-
bency, they sometimesappear to cross.The crura also appear to
be more extensively separated, that is, by up to 2.5 vertebral
lengths, if the animal is slightly rotated or if the x-ray beam is
centeredover the midthorax or cranial thorax.a
or dorsoventral projections varies with centering of the x-ray beam.
The diaphragm may appear as a single, dome-shapedstructure (see
Fig. 29-a), or as two or three separatedomed-shapedstructures
(see Fig. 29-3).The three structures represent the cupula and two
crura. A single, domed diaphragm may be seen on a ventrodorsal
or dorsoventral view when the x-ray beam is centered on the
midabdomen or midthorax, respectively. Two or three separate
domed structures are seen when ihe animal is in the ventro^dorsal
position and the x-ray beam is centered on the midthorax, or
on a dorsoventral view with the x-ray beam centered on the
midabdomen.'
The diaphragmatic position and shape vary with inspiration,
expiration, and intra-abdominal pressure.The normal intersection
point of the diaphragm and spine is between Tl1 and T13 but
may vary between T9 and Ll. The diaphragm changes position
with normal respiration from one-half to two vertebral lengths. On
extreme inspiration, the diaphragm changes position and shape.
On a lateral thoracic view made in extreme insoiration. the dia-
phragm is oriented more vertically;the shapechangesfrom convex
to straight. The diaphragm is displacedcranially by increasedintra-
abdominal pressure,which may be causedby obesity,ascites,gastric
or intestinal distention, abdominal pain, and abdominal masses,
Separate diaphragmatic structures are not seen as distinctly in
the cat, probably becauseof the relatively small thoracic size (Fig.
29-5). On extreme inspiration, particularly if the animal is in
respiratory distress,small symmetrical muscle projections are noted
from the thoracic diaphragmatic surface in the ventrodorsal or
dorsoventralview (Fig. 29-6).
I Radiographicsigns of
I diaphragmatic disease
The signs associateddirectly with the diaphragm are not as numer-
ous and specific as those that are found in many other organs.
Radiographic changes observed most frequently with diaphrag-
matic diseaseinclude generalor local outline loss of the thoracic
diaphragmatic surface and changes in diaphragmatic shape and
position (Table 29-1).
The thoracic diaphragmatic surface outline may be obliterated

Table 29-1. Radiographic signs of diaphragmatic disease

Radiographicsigns Causes
Gen era lloss of diaphr agm at ict hor ac ic Bilat er a lp l e u r a lf l u i d
su rfaceo utlin e G ener a l i z e dp u l m o n a r yd i s e a s ei n c a u d a l l u n g l o b e s
Localizedor oartial loss of the thoracic Thoracicmassesadjacentto the diaphragm
su rfaceo utlin e Diaphr a g m a t i ch e r n i a s
Foc alpu l m o n a r yd i s e a s ei n c a u d a l l u n g l o b e s
Sh ap e ch an ge s Thoracicmassesadjacentto the diaphragm
Hiat alh e r n i a s
Sm all d i a p h r a g m a t i ch e r n i a s
Pleuralreactionon the diaphragmaticsurface
Neopla s i aa r i s i n gf r o m t h e d i a p h r a g m
Hem ipa r a l y s i so f t h e d i a p h r a g m
Unilat e r atl e n s i o n p n e u m o t h o r a x
Positionchanges
Cran iald isp lacem ent Obesity
Per it on e afll u i d
Abdom i n a l p a i n
Abdominal massesor organ enlargement;liver enlargementand massesfrequentlycause
c r ani a ld i s o l a c e m e n t
G ener a l i z e dd i a p h r a g m a t i cp a r a l y s i s
Cranialdisplacementof the cupula causedby a diaphragmaticdefectwith the
peritoneumand pleura intact
Cau da ld isp lac em ent Severerespiratorydistress-ventilationor perfusionproblems
Tensiononeumothorax
Caudaldisplacementof the cupula caused by contactwith the heart
 ANIMALS
3,62 NECKAND THORAX-CON/IPANION

Figure 29-5. Radiographs of the diaphragmatic regionof a

normalcat. A , Left l ateralrecumbentvi ew . B , R i ght atera l
recumbentview. C, Ventrodorsalview. The right /B/ and left
/L/ daphragmati crura
c are al mostsuperi mposed on both re-
cumbentvi ew sw i th l i ttl echangei n posi ti on.The body (8/ has
a convexshapeproj ecti ng i ntothe thorax.l n C the di aphragm
projects as a single convex opacity into the caudal thorax
{arrowst.

Figure 29-6, Ventrodorsalview of the diaphragmaticregion of a normal cat on deep
i n s p i r a t i o nS. m a l l ,r e g u la r lysp a ce dp r o je ctio n s( a r r o ws)a r e evi dental ongthe thoraci cdi a-
p h r a g m a t rscu r f a c e.T h is so - cale d te n tin gr e fle ctsth e p u llingof the di aphragmagai nsti ts
costalattachments.
or not visualized radiographically if anything of the same opacity,
such as organs of soft-tissueopacity and fluid, is adjacentto the
surface.Changesin the diaphragm shapeoccur most frequentlyon
the cupula; they are often normal and are causedby contact with
the heart (Fig. 29-7) or by the position of the animal during
radiographicexamination.The shapeand position may alsoappear
altered in some large-breeddogs, with the body appearingmore
convex and extending to a more cranial position in the thorax.
This may be the result of a flaccid tendinous membrane, or it may
be associatedwith a peritoneopleuralhernia, which often produces
no clinical signs.
Thoracic masses,or lung disease,adjacent to the diaphragm,
hiatai and small traumatic diaphragmatichernias,massesoriginat-
ing from the diaphragm, and chronic pleural inflammatory reac-
tions are the most frequentcausesof shapechanges.An asymmetri-
cal diaphragmatic shape may occur with unilateral tension
pneumothorax or hemiparalysis.Suspectedhemiparalysisshould
be confirmed by observing diaphragmatic movement during fluo-
roscopy.
Positional changesconsist of cranial and caudal displacement.
Becausethe position of the diaphragm changesduring the respira-
Figure 29-7. Ventrodorsalview of the diaphragmatrcregion of a
normal dog. A cardiac impression (solid arrows) is present on the
diaphragmatic body (cupula).The left diaphragmatic crus (openarrows)
i s d i s t i n c t l yv i s i b l e T d s a separate
. h e r ig h t cr u s ca n n o tb e visu a lize a
structure.
The D iaohr aom 363
tory cycle, minor changes are difficult to diagnose and in most
instancesare not clinically significant. Severepositional changes
may be significant and indicative of thoracic or abdominal disease.
Cranial diaphragmatic displacement is usually associatedwith ab-
dominal disease(see Table 29-1) or generalizeddiaphragmatic
paralysis,which should be confirmed with fluoroscopic observa-
tion. Caudal diaphragmaticdisplacementis usually associatedwith
severerespiratorydisease(Fig. 29-8). The caudallypositioned dia-
phragm is an attempt by the animal to increase the level of
systemicPOz,which may be low becauseof ventilation or perfusion
deficienciesin the lungs. Bilateraltension pneumothorax may also
cause a caudally displaced diaphragm from increasedpleurai pres-
sure. In most instances of pneumothorax, however, the caudally
displaceddiaphragm is probably an attempt to increaserespiratory
ventilation.
Although many of the radiographicsigns of diaphragmaticdis-
ease are not specific, they should be observed and their cause
should be determined. In some instances,additional radiographic
studies,such as positional views using a horizontally directedx-ray
beam and contrast medium studies, may be indicated to determine
the causeof the radiographicsigns.
rrrlg
iiil!l
tlllll
iou.
364 NE CKA ND T H OR AX -C OMP AN IO A
NN IMA LS

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.

I Diaphragmatic diseases that may be recognizedradiographicallyinclude traumatic, perito-

The most frequently observeddiaphragmaticdiseasesin the dog
and cat are traumatic and congenitallypredisposedhernias.Motor
or innervation disturbances occur less frequently.
Diaphragmatic hernias
A diaphragmatic hernia is a protrusion of abdominal viscera
through the diaphragm into the thorax. Diaphragmatic hernias
neopericardial,hiatal, pleuroperitoneal,and those secondary to
congenitaldiaphragmaticdefects.
Abdominal trauma is the most common causeof diaphragmatic
hernia. A high momentary increasein abdominal pressurewhen
the glottis is open producesa high pleuroperitonealpressuregradi-
ent that may result in a diaphragmatichernia. The high pleuroperi-
toneal gradient may produce a rent in the muscular portion of the
diaphragm, or it may force abdominal viscera through congenitally

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.

weak or defective areas.Clinical signs that may be observed with
diaphragmatic hernias include dyspnea, pain, vomiting, regurgita-
tion, muffled heart sounds, and a weak femoral pu1se.lu Some
diaphragmatic hernias may not causeclinical signs and are detected
incidentally.
Radiology plays an important role in confirming a diagnosis of
diaphragmatic hernia and may provide information about location,
extent, contents, and secondary complications associatedwith the
hernia.t-tt If a diagnosiscannot be confirmed from survey radio-
graphs (Table 29-2), additional imaging procedures may be per-
formed to add further diagnostic information. The radiographic
procedures consist of administration of barium suifate per os,
positional radiographic views, removal of pleural fluid and re-
radiographing the thorax, and peritoneography.
To ascertain the position of the stomach and proximal small
bowel, a small amount (20 to 40 mL) of barium sulfate (30% w/v)
can be given per os and radiographs obtained after 15 to 20 minutes
Figure 29-1O. Ventrodorsal(A), lateral/8/, and dorsal recumbent,horizontal-beam
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
dorsally,and a soft-tissueopacityis seen betweenthe heartand the sternum
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
a d i a p h r a g m a thi ce r nia .
The D iaphr agm 365
(Fig. 29-9). Radiographs made with a horizontal x-ray beam help
identi$' solid organ structures (Fig. 29-10). Thoracocentesisand
pleural fluid removal followed by another radiographic examinarion
provide better radiographic visualization of thoracic structures.Posi-
tive-contrast peritoneography can be performed by injecting 2 mL/
kg of body weight of an iodinated contrast medium into the perito-
neal cavity. The animal should then be positioned such that gravity
facilitates contrast medium accumulation around the liver and the
diaphragm. Contrast medium within the thorax and incomplete
visualization of the abdominal surface of the diaphraqm are the
most consistent positive-contrast peritoneographic'signi of a dia-
phragmatic hernia (Fig. 29-171.,L13Any or all of these procedures
may be used, but the most simple proceduresshould be used first.
Peritoneography should be used after other diagnostic procedures
have failed to provide the neededinformation.
Other procedures,including positive-contrast pleurography, por-
tography, cholecystography, angiocardiography, angiography, and
laleral (C) views of a dog with a traumaticdiaphragmatichernia.,4, An
c outl i neoverthe cupul ai s show n. B , Th e hearti s di s pl ac ed
(arrows). The thoracicdiaphragmatic outlineis indistinctover the cupua. C The soft-
w l tl "
366 NE CKA ND T H OR AX -C OMP AN IOA
NN IMA LS

Traumatic diaphragmatic hernias

In one study, only one half of the animals presenting with a
traumatically induced diaphragmatic hernia had a history of known
trauma.6 Traumatic diaphragmatic hernias usually involve the mus-
cular part of the diaphragm.6'te In one report, it was suggested
that there is equal incidence on the right and the leftls; another
report stated that there was a higher incidence on the right side in
the dog.6 The organs that most frequently herniate through the
diaphragm (in order), are the liver, small bowel, stomach, spleen,
and omentum.6'e'Ie 21
The most consistentradiographic signs of traumatic diaphrag-
matic hernia are abdominal viscerawithin the thorax; displacement
of abdominal or thoracic organs,or both; partial or completeloss
of the thoracic diaphragmaticsurfaceoutline; asymmetryor altered
slopeto the diaphragm on the lateralprojectionrl;and the presence
of pleural fluid (Fig. 29-12).
Identification of abdominal structuresin the thorax is a conclu-
sive sign of diaphragmatic hernia. Small bowel is easily identified
when it is gas-filled; when fluid-filIed, it appears as a tubular
structure. The stomach may be filled with gas, fluid, or ingested
material. In addition, gastric rugal folds may provide a marker for
identi!'ing the stomach within the thorax. A herniated, gas-dis-
tended stomach may appear as a unilateral left pneumothorax, and
Figure 29-11. A lateralabdominalradiograph perito-
of a positive-contrast the stomachshould be decompressed and repositionedimmediately
neogram. outlineto the abdominal
Thereis an indistinct surfaceof the dia- by surgical intervention (Fig. 29-13).6 Such instances are life-
phragmlsmal/arrows),withcontrastmediumpresentwithinthe p euralcavlty threateningbecauseof potential or actual cardiovasculartampon-
Thesearereliable
largearrows). radiographic defect
slgnsof a diaphragmatic
hernia.
anda draphragmatic
Herniated solid abdominal parenchymal organs are difficult to
distinguish from localized pleural fluid, pulmonary opacity, or
both. Omentum is the most difficult to detectunlessit is herniated
nonselectivecardiography,have been reported as useful in diagnos- in associationwith other abdominal organs. In such instances,it
ing diaphragmatic hernias.'aThese techniquesare more difficult provides a fat opacity and helps outline other abdominal visceral
and usuallydo not provide more information than commonly used organs.
Droceoures. In the absenceof identifying abdominal organs in the thorax,
Ultrasonographicexamination of the diaphragm may add diag- cranial abdominal organ displacementor absenceof abdominal
nostic information in difficult patients, particularly those in whom organsfrom their normal location is an indirect sign of diaphrag-
pleural fluid is present and obliterates soft tissue. The examination matic hernia. The liver, spleen,small bowel, and stomach are the
is best done transhepatically.rs Ultrasonographic signs of a dia- organsthat must be assessed most closelyfor displacement.Includ-
phragmatic hernia include identification of abdominal structures ing the cranial abdomen on the thoracic radiograph when dia-
within the thorax, particularly the liver, and an interruption in the phragmatic hernia is suspectedis helpful in the evaluation of
diaphragmatic outline.r5-r7An interruption in the diaphragmatic abdominai organ displacement.Barium sulfatemay alsobe admin-
outline may not be consistentlyseenwith diaphragmatichernias.t8 istered to identify the stomach and to help detect mild to moderate
gastricdisplacementnot observedon survey radiographs.
The heart, mediastinum, and lungs may also be displaced,de-
pending on the number and position of abdominal organs within
Table 29-2. Radiographic signs associated with the thorax. The heart and lungs are usually displaced cranially and
traumatic diaphragmatic hernia laterally by herniated abdominal viscera,and the mediastinum is
usually displacedlaterally.A localized diaphragmatic surfaceoutline
A bdomin alviscerawit hin t he t hor ax
Gas- or ingesta-filledbowel loss usually indicates the area through which the diaphragmatic
Gas- or ingesta-filledstomach hernia has occurred. Abdominal viscera and pleural fluid adjacent
lden tifiab lepa ren c hy m alor gans ,s uc h as t he liv er an d s p l e e n to the thoracic diaphragmatic surface cause the outline loss. This
D isola ce menot f a bd om inals t r uc t ur es - c r anial occurrence must be distinguished from the many other thoracic
Liver conditions that produce a soft-tissueopacity adjacentto the dia-
S m a ll bo wel phragm. Pleural fluid is consistentlypresent with chronic diaphrag-
Stomach matic hernias,or if a herniated abdominal organ, most usually the
S plee n Iiver,2l is strangulated through a small diaphragmatic opening.
Displacementof thoracicstructures-generallydisplacedcranial Pleural fluid is a nonspecific sign of diaphragmatic hernia and
and la tera lawa y fr om an abnor m alopaque ar ea in th e t h o r a x often masks other more important radiographic signs. Thoraco-
Heart centesis and aspiration of the pleural fluid are often necessary
Me dia stin um before the hernia can be detected radiographically.
L un gs
Partialor complete loss of the thoracicdiaphragmaticsurface
ou tline
Congenitally predisposed diaphragmatic
Pleu ralfluid or m as s hernias
Lu ng flu id o r mas s Approximately 15o/oof all diaphragmatic hernias are congenitally
Div e rge nceo f d iap hr agm at icc r ur a or c r anialangulat i o no f predisposed.nIncluded in this group are peritoneopericardialdia-
diap hra gm phragmatic hernias, hiatal hernias, and diaphragmatic defects.Her-
P leura lflu id niation in association with congenital diaphragmatic defects may
 The Dlaphragm 367

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,.

Figure 29-13. Ventrodorsalviews of the

t h o r a xo f a d o gw i t h a tr a u m a ticd ia p h r a g m a tic
h e r n i aw r t h o u t1 A Ja n d with /B/ b a r iu min th e
s t o m a c hA . , T h e g a s{ il1 estod m a ch( a r r o ws) is
h e r n i a t e di n t o t h e l eft h e m ith o r a x,
sim u la tin g
a u n i l a t e r at el n s i o npn e u m o th o r a x;
it d isp la ce s
t h e h e a r t a n d l u n g s to th e r ig h t sid e . T h e
n o r m a lg a s t r i ca n d l e ft d ia p h r a g m a tic
o u tlin e s
^r a
n^t nr aaanr A Rarirrm ic

cranialpart of the stomach(anows),and there

nroconr

i s s e v e r eg a s e o J Sg a str icd iste r tio n .

rn rno

,-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
increase in intra-abdominal pressure. Defects in diaphragmatic
development may be present and never result in a hernia.
Peritoneopericardial diaphragmatic hernias
With a peritoneopericardialdiaphragmatichernia, abdominal vis-
cera herniates into the pericardial sac through a congenital hiatus
formed between the tendinous portion of the diaphragm and the
pericardial sac. This has been reported to occur in litter mates,22
and it has been suggestedthat this trait is carried on a simple
autosomal recessivegene in cats, with a 1:500 to 1:1500 rate of
incidence.'z3The hernia may have been present from birth or it
may be acquired.Mild increasesin intra-abdominal pressuremay
causeabdominal organs to herniate through a congenital hiatus.
Peritoneopericardial hernias may produce clinical signs, or they
may be an incidental radiographic finding. These hernias may be
present in old or young animals.s'2428The liver is most frequently
herniated; the stomach, omentum, and small bowel have a less
frequent occurrence of herniation.'ze
Radiographicsigns associatedwith peritoneopericardialhernias
arelisted in Table29-3. Herniatedabdominal organsin the pericar-
dial sac are usually caudal, or caudal and lateral, to the heart. Gas-
or ingesta-filled hollow visceral organs are not difficult to identify
within the pericardial sac. Radiographically, gas within the bowel
is in abrupt contrast to the adjacentstructuresof soft-tissueopac-
ity. Solid parenchymal organs, unless surrounded by omentum, are
difficult to distinguish as separate structures within the pericar-
dium. When abdominal organs are herniated into the pericardial
sac, cranial and ventral organ displacementwithin the abdomen
may be seen,but this displacementis usually not as pronounced
as that noted with traumatic diaphragmatichernias.
A large, round cardiac silhouette and a cardiac silhouettewith
an abnormal convex projection on the caudal border are signs
consistentwith peritoneopericardialdiaphragmatichernias. These
two signs are dependent on the amount of abdominal viscera
within the pericardial sac. Large amounts of viscera produce a
large, round cardiac silhouette,whereassmaller amounts, such as
a portion of the liver or stomach, may produce an abnormal
convex caudal cardiac border. A large, round silhouette must be
differentiated from pericardial effusion, generalizedheart enlarge-
ment, or both. An abnormally convex caudal cardiac border must
be differentiatedfrom neoplasia,pleural granulomas,or localized
oleural fluid.
An indistinguishable outline to the ventral diaphragmatic surface
and the caudal ventral cardiac silhouette is produced by the com-
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
Tahle 29-3. Radiographic signs associated with
peritoneopericardial diaphragmatic hernias
A bdomina l o rga ns ide nt if iedin t he per ic ar dials ac ;gas ,
ingestedmaterial.or structuresof soft-tissueopacity may be
oresent
Large,round cardiacsilhouette
Convex projectionof the caudal cardiacsilhouette
b or der of t he v ent r alt hor ac icdiaphr a g m a t i c
Indistin gu ish ab le
surfaceand the caudalventral cardiacsilhouette
Confluentsilhouettebetweenthe diaphragmand the heart
Dorsalperitoneoperica rdial mesothelialremnant betweenthe
heart a nd d iap hra gmon t he lat er alv iew in c at s
mesothelialremnant betweenthe heart and diaphragm is a consis-
tent radiographic sign of peritoneopericardialhernia in cats (Fig.
29-147.'o Additional radiographic studies that may be performed
to confirm a diagnosis include administration of barium sulfate
per os, nonselective angiography,tt and peritoneography. Barium
sulfate may be used to demonstrategastrointestinalstructures
within the pericardial sac or cranial ventral displacement of ab-
dominal structures(Fig. 29-15).
Peritoneographywith negative- or positive-contrast medium may
be used to evaluate for the presence of a peritoneopericardial
hernia. For peritoneography, the animal is positioned to allow
gravitation of contrast medium from the peritoneum into the
pericardial sac, or to outline the abdominal surface of the dia-
phragm. This maneuver may not be successfulbecauseof the
inability of contrast medium to flow through a small or obstructed
hiatus. Nevertheless,a defect in the outline ofthe peritoneal surface
of the diaphragmmay be outlined.',
Ultrasonography has also been used to successfully diagnose
peritoneopericardialdiaphragmatichernias.r5t8
Hiatal hernias
Hiatal hernias are produced when a portion of stomachentersthe
thorax through the esophagealhiatus. Thesehernias are reported to
occur through a congenitally or traumatically enlarged esophageal
hiatus; they also may result from contraction of the longitudinal
esophagealmuscle.3t' 33
There are two recognized types of hiatal hernias.a:sliding and
paraesophageal. The gastroesophageal sphincter and a portion of
the stomach, usually the cardia, are herniated into the thorax with
sliding hiatal hernias.35
Sliding hiatal herniasare usually congenital
and seen in younger animals.3nThey are often associatedwith
esophagitisfrom gastroesophageal reflux. As the name implies, the
caudal esophagusand the cardia slide intermittently from the
abdomen into the thorax. Becausethe hernia is dynamic, it may
not be seen on any one radiograph; fluoroscopic examination is
often necessaryto make a diagnosis.Patientswith nonsliding hiatal
hernias have been reported, with the gastroesophagealsphincter
and the gastric cardia displacedthrough the esophagealhiatus and
fixed within the thorax.36Only a few sliding hiatal hernias have
been reportedin animals.3T-aa The low incidencemay be a reflection
of the subtle clinical signs and intermittent manifestations on
survey radiographs.
A paraesophageai hiatal hernia is produced when the cardia or
cardia and fundus of the stomach herniate through, or alongside
of, the esophagealhiatus and become positioned adjacentto the
Figure 29-14. Lateralview of a feline thorax.The cat has a peritoneoperi-
cardi aldi aphragmatiherni
c a.The fai nt outl i neof a dorsalperi to neoperi c ardi al
mesothelialremnant is present cranialto the diaphragm(open arrowd. fhe
l i ver,omentum,and spl eenare herni atedi nto the peri cardi alsac .The c audal
border of the heart is visible (blacksolid affowsl becauseof fat in the adia-
cent omentum.
 The Diaphragm 369

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
thorax and abdomen, and the gastroesophageal sphincter is in a
normal position.3r3s'45The herniated stomach may causeesopha-
geal obstruction from externalpressureon the caudal esophagus.
Hiatal herniashavebeen reported in both the dog and the cat.36,
3e'4t-44They have been reported associatedwith other esophageal
conditions (such as) in Chinese Shar pei dogs.aa Clinical signs
reported with hiatal herniasinclude vomiting, regurgitation,exces-
sivesalivation,dysphagia,and dyspnea.3o' 43'44Hiatal hernia may be
suspectedfrom the clinical signsand survey radiographicfindings,
but it must be confirmed with an esophagram.
Radiographicsigns of a sliding hiatal hernia are listed in Table
29-4. The most consistentsurvey radiographic sign is stomach
displacement. The cardia appears to be stretched toward the dia-
phragm or may extend into the thorax. This displacementproduces
Tahle 294. Radiographic signs associated with sliding
hiatal hernias
an abnormal shape to the cardia and fundus remaining in the
abdomen. The caudal esophagusmay or may not be distended,
and a soft-tissueopacity (mass) may be seen adjacentto the left
diaphragmatic crus (Fig. 29-16). The size and visibility of this
massdependon the amount of stomachthat has actuallyherniated
into the thorax. The soft-tissuemassassociatedwith a hiatal hernia
must be differentiatedfrom a pulmonary mass or a massoriginat-
ing from the diaphragm. Diaphragmatic neoplasticmasseshave
been reported,but are rare.a6
A dilated caudalesophagusis usuallybest detectedand evaluated
with an esophagram.An esophagramis alsohelpful for differentiat-
ing the type of hiatal hernia. The caudal esophagealsphincter and
a portion of the cardia are seen cranial to the diaphragm with a
sliding hiatal hernia.aTThe caudal esophagealsphincter can be
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
the herniated stomach (Fig. 29-18).

Survey radiographs Gastroesophageal intussusception

Soft-tissuemass adjacentto the left diaphragmaticcrus Gastroesophageal intussusceptionsoccur when the stomach,with
Lo ss of th ora ci cs ur f ac eout lineon t he lef t diaph r a g m a t i cc r u s
or without the spleen,duodenum, pancreas,and omentum, invagi-
Cra nia ld isp lacem entof t he gas t r icc ar dia,pr odu c i n ga n
ab no rmalga s t r ics hape nates through the esophagealhiatus into the caudal esophagus.33,
35'48'4eThey occur mostly in
Dila tede so ph agus male and German shepherddogs and
Pn eu mon ia in animalswith a preexistingdilated esophagus.rn Gastroesophageal
Esophagram rntussusceptions usually produce an esophagealobstruction,which
Dilatedesophagus results in rapid deterioration of the animal's condition with a high
Hypo motilee so phagus mortality rate; therefore,a timely diagnosisis essential.ae
Gastroesophageal sphincterwithin the thorax representedby On survey radiographs,a large soft-tissuemass is seenadjacent
a circu mfere nt ially nar r owedar ea of t he es oph a g u s to the diaphragm, usually accompaniedby a dilated esophagus.
Ga stricca rdiawit hin t he t hor ax
With an esophagram,gastroesophageal intussusceptionsproduce a
Gastroesophageal reflux
large intraluminal filling defect within the caudalisophagus, rugal
 37O NE CKA ND T H O R AX -C OMP AN IO A
NN IMA LS

Figure 29-16. Lateralthoracicview with a soft-tissueopacityin the

caudodorsalthorax (arrows).The soft-tissueopacityhas gas within the
centerand i s suspectfor a hi atalherni a.

Figure 29-17. Lateralviews of barium esophagramin a

pat ie n tw i t h a s l i d i n gh i a ta lh e r n ia A,
. Co n tr a stm e d iu md is-
t endst h e c a u d ael s o p h a g u /E/, s th e g a str o e so p h a g esp a lh in c-
tet (arrows), and the cardiaicl. The gastroesophageal sphinc-
t er an d g a s t r i cc a r d i aa r e d isp la ce dcr a n iatol th e d ia p h r a g m
through the esophagealhiatus. 8, The esophagusiEl and
gastroesophageal sphincter (arrows) are outlinedbut are not
dis t e n d e dw i t h b a r i u m ;mo st o f th e b a r iu mh a s p a sse din to
t he s to m a c h .T h e g a s t r o e so p h a g e asp
l h in cte ra n d g a str ic
c ardi aa r e h e r n i a t e dt h r o u g hth e e so p h a g e ahl ia tu sa n d a r e
c rani atlo t h e d i a p h r a g m.

Figure 29-r8. Lateral viewof thethorax.Bariumis outininga paraesopha- ln anlmals.
gealhiatalhernia.The bariumoutltnesthe gastriccardia(arrows),whichis
cranialto the diaphragm.The cardiahasherniated throughthe esophageal ysis, bilateral paralysis,and diaphragmaticflutter.r Diaphragmatic
hiatus adjacentto thecaudal
esophagus, whichis notopacified.
folds may be outlined with barium, and barium usually does not
enter the stomach (Table 29-5 and Fig. 29-19).
Diaphragmatic defects
Congenital diaphragmatic defectsin the dog and cat have been
reported rarely.s0-5a The defects are created when the septum
transversum or the pleural peritoneal folds do not develop and
fuse to form a complete diaphragm. The diaphragmatic defect
allows abdominal viscera to enter the thoracic cavity and may
produce clinical signs consistentwith a traumatic diaphragmatic
nernla.
In humans, diaphragmatic defectshave a familial incidence with
a multifactorial mode of inheritance.ssCongenitaldefectsin dogs
have been reported in the muscular diaphragm, dorsolateral in
position,56and in the membranous diaphragm, associatedwith
umbilical hernias.sr-53
The radiographic signs of congenital diaphragmaticdefectsare
the same as those listed for traumatic diaphragmatic hernias. With
membranous defects,however, the liver (in dogs) or the falciform
fat (in cats) is displaced cranially, while remaining in the caudal
Figure 29-19. Lateralradiographof the caudodorsal
t h e t h o r a xo f a d o g with a g a str o e so p h a g ein
Bariumoutlinesits cranlalaspecl (arrows).The large soft-ttssue
massin the caudad l o r sa th o r a xis th e sto m a chin tu ssu scepted
in t ot h e c a u d ael s o p h a g e alul m e n .No teth e b a r iu mco a tr n go f t he
g a s t r i cr u g a e ;t h r s f e a tu r eis ch a r a cte r istic
o f g a str o e so p h ageal
Inrussusce0ton.
The D i aphr agm 371
Table 29-5. Radiographic signs associated with
gastroesophageal intussusception
Survey radiographs
Soft-tissuemass adjacentto the diaphragm
C r a n i a ld i s p l a c e m e n o t f t h e s t o m a c hw i t h o r wi th o u t th e
s p l e e no r d u o d e n u m
D i l a t e de s o p h a g u s
Esophagram
I n t r a l u m i n afl i l l i n g d e f e c ti n t h e c a u d a le s o p h ag u s
B a r i u mo u t l i n eo f r u g a l f o l d s
No bariumwithin the sromacn
ventral thorax, and is often confined to the mediastinum as the
pleura is intact (Fig. 29-201."u
Motor disturbances of the diaphragm
The diaphragm is the principal muscle of respirationand is inner-
vated by the phrenic nerve. Motor disturbancesin most instances
are clinically asymptomatic and have not been well documented
Motor disturbancesof the diaphragm consistof unilateralparal-
paralysis may result from pneumonia, trauma, myopathies,and
neuropathies,or the cause may be unidentified.r Diaphragmatic
paralysisshould be suspectedwhen there is cranial displacement
of one or both diaphragmatic crura (Fig. 29-2I). Confirmation of
paralysis is best achieved with fluoroscopy. Unequai movement
between the crura is seen with unilateral Daralvsis.With bilateral
paralysis,minimal or no diaphragmaticm;vement, or a paradoxi-
cal cranial displacementof the flacciddiaphragm may occur during
inspiration.5TBilateral paralysismay be more difficult to confirm
with fluoroscopy becausediaphragmaticmovement is sometimes
produced by compensatoryabdominal muscle contraction during
respiration.
Diaphragmaticflutter is most often associatedwith contractions
of the diaphragm synchronous with the heartbeat.It is usually
transient in nature and can be diagnosedeasilywith fluoroscopy
by observing contractions of the diaphragm in synchrony with the
heartbeat.s8
Muscular dystrophy
Muscular dystrophy caused by dystrophin deficiency has been re-
ported in dogss'g 6rIn cats,an irregulaqscallopedappear-
and cats.60'
ance of the diaphragm, particularly along the ventral margin, was
a consistentfinding observedon radiographs after 7 months of
aspectof
a ltu ssu sce ptton.
372 NE CKA ND TH OR AX -C OMP AN IO AN
N IM A LS

lgu

Figure 29-2O. Recumbentlateraiand ventrodorsalviews of a dog (A

a n d B ) a n d a c a t i C a n d D) th o r a x.A d e fe ctin th e m e m b r anousporti onof
the diaphragm i s p r e se n tin b o thth e d o g a n d ca t ln th e d og (A and B ) the
liver (arrows)and gas-filledpyloricantrum (P/ are within the thorax, and
t h e s t o m a c ha n d live r a r e d isp la ce dcr a n ia lly.In th e ca t (C and D ) the
falciformligamentand fat are displacedcranialto the diaphragmlaffowsl
a n d s u r r o u n d ew d i th in ta ctp a r ie tapl le u r a .

Figure 29-21. Ventrodorsal1Aland laterai/B/ radiographs of the crania abdomen.There is hemiparalysis
/LCl is cranialto the right (RQ.fhe cupula/C/and right crus /,QClare in a normalinspiratoryposition.8, ihe cranialpositionof t-helefi diaphragmaiiccius (arrows)
c a u s e st h e g a s t n cc a r diaa n d fu n d u sto b e d isp la ce cr
d a n iavl
age."O The scallopedmargin noted best on the lateral view should
not be confusedwith the normal scallopingobservedon the ven-
trodorsal view in cats on maximum inspiration (see Fig. 29-6).
Muscular hypertrophy produced with feline muscular dystrophy
has also been reported to causemegaesophagus from extraluminal
hiatal obstruction. Definitive laboratory tests,such as immunoflu-
orescenceor immunoblot tests,are necessaryto establishthe diag-
nosis of muscular dystrophy.
References
l. Shim C: Motor disturbanccsofthe diaphragnr.Clin Chest Med l:125, 1980.
2. Rivero O, del Castillo H: Lynphatics of the diaphrargmin the dog. Acta Radiol
(Diagn) (Stockh) 171663,1976.
3. EvansHE: Miller's Anatomy of the l)og,3rd ed. Philadelphia,WB Saunders,1993,
p 304.
4. GrandagcJ;'lhe radiology ofthe dog'sdiaphragm. I Small Anim Pract 15:1,1974.
5. Schulnan i: Peritoneopericardialdiaphragmatichernia in a dog. Mod Vet Pract
6 0 :3 0 6 ,1 9 7 9 .
6. Garson HL, Dodman NH, Baker GJ: Diaphragmatic hernia: Analysis of fifty-six
casesin dogs and cats.J Small Anim Pract 2l:469, 1980.
7. Farrow CS: Radiographic diagnosis of diaphragmatic hernia. Mod Vet Pract
64:979, 1983.
8. Silvernan S, Ackerman N: Radiographicevaluation of abdominal hernias. Mod
V e t P ra ct 5 8 :7 8 1 ,1 9 7 7 .
9. Wilson CP III, HayesHM Jr: Diaphragmatichernia in the dog and cat: A 25 year
overview.Senrin Vet Med Surg 1;318,1986.
10. Levine SH: Diaphragnatic hernia. Vet Clin North Am Snall Anim Pract 17:411,
I 987.
11. Stokhof AA, Wolvekamp WTC, Hellebrekers Ll, et al: Traumatic diaphragmatic
hernia in the dog and cat. Tijdschr Diergeneeskd1I I (suppl t):625, 1986.
12. Rendano VT: Positive contrast peritoneography: An aid in the radiographic diag-
nosis of diaphragmatic hernia. J Am Vet Radiol Soc 20:67, 1979.
13. Stickle RL: Positive-contrast celiography (peritoneography) for the diagnosis of
diaphragmatichernia in dogs and cats.J An Vet Med Assoc 185:295,1984.
14. Willians JLR, Myer CW: Imaging modalities used to confirm diaphragmatic
hernia in snall aninals. Compend Small Anim 20:1199,1998.
15. Lamb CR, Mason GD, Wallace MK: Ultrasonographic diagnosis of peritoneoperi-
cardial diaphragmatichernia in a Persiancat. Vet Record 125;186,1989.
16. Hay WH, Woodfield JA, Moon MA: Clinical, echocardiographic, and radiographic
findings of peritoneopericardial diaphragmatic hernia in two dogs. J Am Vet Med
A s s o c1 9 5 :1 2 4 51, 9 8 9 .
17. Hashimoto A, Kudo T, Sawashima I: Diagnostic ultrasonography of noncardiac
intrathoracic disordersin small animals.ResBull 55;235,1990.
The Diaphragm 373
of the left diaphragm.A, The left diaphragmatic
crus
18. Hodges RD, Tucker RL, Brace l): Radiographic diagnosis (peritoneopericardial
diaphragmatic herniation in a dog). Vet Radiol Ultrasound 341246,i-993.
19. Carb A: Diaphragmatic hernia in the dog and cat. Vet Clin North Am Small Anim
Pract 5:477, 1975.
20. Wilson GP, Newton CD, Burt JK: A review of 116 diaphragmatichernias in dogs
and cats.J Am Vet Med Assoc 159:1142,1971.
21. Iloudrieau RJ, Muir WW: Pathophysiologyof traumatic diaphragmatichernia in
dogs. Compend Contin Educ Pract Vet 9:379, 19g7.
22. Feldman DB, Bree MM, Cohen BJ: Congenitaldiaphragmatichernia in neonatal
dogs. J Am Vet Med Assoc 153:942, t968.
23. Saperstein G, Harris S, Leipold HW: Congenital defects in domestic cats. Feline
Pract 6:18, 1976.
24. Iljorck GR, Tigerschiold A: Peritoneopericardial diaphragmatic hernia in a dog.
I
Small Anim Pract 1l:585, 1970.
25. Gourley IM, Popp ]A, Park RD: Myelolipomas of the liver in a domestic cat.
J
Am Vet Med Assoc 158:2053,1971.
26. Rendano Vl Parker RB: Polycystic kidneys and peritoneopericardial diaphrag_
matic lrernia in the cat: A case report. J Small Anim hact 17:47t, 1976.
27. Wcrtz J, Tilley LR Moldoff D: Pericardiodiaphragmaric hernia in a dog. Am Vet
I
Med Assoc 173:1336, 1978.
28. Evans SM, Biery DN: Congenital peritoneopericardial diaphragnatic hernia in the
dog and cat. Vet Radiol 21;108,1980.
29.. Neiger R: Peritoneopericardial diaphragmatic hernia in cats. Compend Contin
Educ Pract Vet l8:461, 1996.
30. Berry CR, Koblik PD, Ticer JW: Dorsal peritoneopericardial mesothelial remnant
as an aid to the diagnosis of feline congenital peritoneopericardial diaphragmatic
hernia. Vet Radiol 3l:239, 1990.
31. Willard MD, Aronson E: Peritoneopericardial diaphragmatic hernia in a cat. An
)
Vet Med Assoc 178:481,1981.
32. Edwards MH: Selective vagotomy of the canine oesophagus: A model for the
treatment of hiatal hernia. Thorax 31:185,1976.
33. TeunissenGHB, Happ RP, Van Toorenburg J, et al: Esophagealhiatal hernia: Case
report of a dog and a cheetah. Tijdschr Diergeneeskd 103:742, 1978.
34. Ellison GW, Lewis DD, Phillips L, et al: Esophagealhiatal hernia in small animals:
Literature review. I Am Anim Hosp Assoc 20;783, 19g4.
35. Ellis FH Jr: Controversies regarding the management of hiatus hernia. Am Surg
J
139:782,1980.
36. Prymak C, Saunders HM, Washabau RJ: Hiatal hernia repair by restoration and
stabilization of normal anatomy. An evaluation in four dogs and one cat. Vet Surg
18:386,1989.
37. Rogers WA, Donovan EF: Peptic esophagitis in a dog. J Am Vet lvled .\ssoc
163:462,1973.
38. Gaskell Cl, Gibbs C, Pearson H: Sliding hiatus hernia with reflex oesophaeitis in
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.

41. Robotham GR: Congenitalhiatal hernia in a cat. Feline Pract9:37,1979.

42. PetersonSL: Esophagealhiatal hernia in a cat. J Am Vet Med Assoc 183:325,1983.

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.

44. Stickle R, Sparschu G, Love N, Walshaw R: Radiographic evaluation of esophageal

function in ChineseShar Pei pups. J Am Vet Med Assoc201:81,1992.

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.

48. Pollock S, Rhodes WH: Gastroesophagealintussusception in an Afghan hound. l

Am Vet Radiol Soc 11:5, 1970.

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.
55. WolffG: Familial congenitaldiaphragmaticdefect:Reviewand conclusions.Hum
Ge n e t 5 4 :1 ,1 9 8 0 .
56. Voges AK, Hill RC, Neuwirth L, Schaer M: True diaphragmatic hernia in a cat.
Vet Radiol Ultrasound 38:116,1997.
4. Identif ing abdominal structureswithin the thorax is patho-
gnomonic for diagnosinga diaphragmatichernia. What two other
radiographicsigns are most crediblefor identif,iing diaphragmatic
hernias?

57. GreeneCE, BasingerRR, Whitlield JB: Surgicalmanagementofbilateral diaphrag-
matic paralysisin a dog. I Am Vet Med Assoc 193:1542,1988.
58. Mainwaring CJ: Post-traumatic contraction of the diaphragm slnchronous with
the heartbeat in a dog. I Small Anim Pract 29:299, 1988.
59. Cooper Bl, Winand NJ, Stedman H, et al: The homologue of the Duchenne locus
is defectivein X-linked muscular dystrophyof dogs. Nature 334:154,1988.
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 .
61. Gaschen FP, SwendrowskeMA: Hypertrophic feline muscular dystrophy. A unique
clinical expression of dystrophin deficiency. Feline Pract 22:23, 1994.
K Ouestions
l What two factors relating to physical alignment during the
radiographic examination affect the appearanceof the diaphragm
on a dorsoventralor ventrodorsalradiograph?
2. On a recumbent lateral radiograph of the thorax, which dia-
phragmatic crus is displaced cranially?
3. The thoracic surface of the diaphragm is easily visualized
radiographically becauseof the adjacent air-filled lungs. What con-
ditions obliterate or cause the diaphragmatic surface not to be
visible radiographically?
5. You observea mass in the caudal dorsal thorax on a lateral
view What is your differential diagnosis?
6. What contrast examination procedure would provide addi-
tional information to help differentiatea hiatal hernia from other
possiblemassesin this region?
7. What radiographicsign is a consistentfinding with muscular
dystrophyin cats?
8. What radiographic signs can be identified on the lateral and
ventrodorsalthoracic radiographs (see Figs. 29-22A and B), and
what is your specific or differential diagnosis?
9. What other diagnosticimaging modalitiesor techniquescould
be usedto help determinea specificdiagnosis(referringto Fig.29-
?r\
10. What radiographic signs are present on the lateral decubitus
views (Fig. 29-23A and B) and the upper GI study (Fig. 29-2a)
that would confirm the diagnosis of a traumatic diaphragmatic
hernia in the right caudal thorax?
Answers begin on page 727,
 CHA P T E R

30
The Mediastinum
. Donald E. Thrall

I Normal anatomy fenestrated.Some sourcessuggestthat it is,l whereasothers suggest

The mediastinum consists of the two layers of mediastinal pleura
and the space between them. The two mediastinal pleural layers
are part of the right and left pleural sacs. Each pleural sac is
composed of mediastinal, diaphragmatic, costal, and pulmonary
pleurae (Fig. 30-l). These pleural components are continuous.
When speaking of the mediastinum or mediastinal disease,one is
usually referring to some abnormality involving the spacebetween
the two layers of mediastinal pleura rather than a primary abnor-
mality of a mediastinal pleural layer.
The mediastinum extends from the thoracic inlet to the dia-
phragm and is primarily located in the median plane of the thorax,
essentially dividing the thoracic cavity into right and ieft halves
(Fig. 30-2). The mediastinum may be subdivided into a cranial
portion cranial to the heart, a middle portion at the level of and
containingthe heart, and a caudalportion caudalto the heart. The
mediastinum may also be divided into dorsal and ventral portions
by a dorsal plane through the tracheal bifurcation. Organs included
in the mediastinum are listed in Table 30-1.
There is controversy regarding whether the mediastinal pleura is
it is not.'z Regardlessof whether the mediastinal pleura is fenes-
trated or is just extremely fragile, it is common for pleural space
diseaseto be bilateral (i.e., not contained to one pleural cavity by
the mediastinum).For example,in one study of induced pneumo-
thorax in dogs,22 of 24 dogs having air injected into one pleural
spacequickly developedbilateral pneumothorax.3 Unilateral pleural
space diseaseor pleural space diseasewith asymmetrical distribu-
tion may occur if (1) the mediastinum is not fenestratedor the
mediastinal pleura remains intact, (2) existing fenestrations have
been closed by inflammatory disease,or (3) the pleural space
contents are too large or viscid to pass through any existing fenes-
trations.
The mediastinum, in contrast to the pleural space,is not a
closed cavity. The mediastinum communicates cranially with the
fascial planes of the neck via the thoracic inlet. Caudally, the
mediastinum communicates with the retroperitoneal spacethrough
the aortic hiatus. These communications orovide the means for
the spread of mediastinaldiseaseto the nick and abdomen, and
vice versa.
Of the mediastinal organs listed in Table 30-1, only the heart,
trachea, caudal vena cava,aorta, and, in young animals, thymus are
visible in normal thoracic radiographs.Occasionally,the normal
esophagusmay be seen(seeChapter 25). Other mediastinalorgans
are not seen because(1) they are not large enough to absorb a

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

COST ALPARIET ALPL EU R A

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

Table 30-1. Mediastinal organs

Cranial mediastinum Middle mediastinum Caudalmediastinum
Cranialvena cava X
Thymus X
Ste rna llymph no des X
Aortic arch X
Brachio ce ph alic ar t er y x
Left subclavianartery X
Me dia stin allymph nodes X
Trachea X X
Right and left vagosympathetictrunk X X
Dorsal intercostalarteriesand veins X X x
In tern alth ora cica r t er iesand v eins X X X
Eso ph ag us X X X
Thoracicduct X x x
Right and left sympathetictrunks X X X
Right and left phrenic nerves X x X
Descendingaorta X x
Bronchoesophageal arteriesand veins X X
Azygousvein X X
Heart X
Tracheobronchial lymph nodes X
M a in pu lmon aryar t er y X
M a in pu lmon aryv eins X
Prin cip albro nchi X
Caudalvena cava
Right and left vagus nerves

sufficient number of x-rays, (2) there is insufficient fat in the
mediastinum to provide contrast, or (3) they are in contact with
other mediastinalstructuresof the sameradiopacityand cannot be
seenbecauseof the silhouettesign. An example of silhouetting of
mediastinalstructuresis the appearanceof the cranial mediastinum
in a lateral thoracic radiograph.A distinct opacity is usuallyvisible
in the cranial mediastinum ventral to the trachea,but individual
organs cannot be discerned(Fig. 30-3). This opacity is due to the
absorption of x-rays by cranial mediastinal organs, that is, the
left subclavian artery, brachiocephalic trunk, cranial vena cava,
mediastinallymph nodes, and possibly thymus. These organs are
not seen individually becausethey are in contact with each other,
and typically there is insufficient fat interspersed between these
organs.Thus, the margin of thesevesselsin the cranial mediasti-
num is obliterated.On the lateral projection, the cranial mediasti-
num is more radiopaquejust ventral to the tracheathan just dorsal
to the sternum becauseof the greaterthicknessof the mediastinum
ventrally (Fig. 30-4; seealso Fig. 30-3).
In ventrodorsal or dorsoventral thoracic radiosraphs, most of
the cranial mediastinum is superimposedon the"spine, and the
width of the mediastinum is usually less than approximately two
times the width of the vertebrae(Fig. 30-5). In obesepatients,the
cranial mediastinum may be widened by fat accumulation, and
the resultant opacity can be confused with a mediastinal mass
(Fig. 30-6).
There are three mediastinal reflections, onlv the first two of
which are frequently identified in normal thoracic radiographs:
(1) the cranioventral mediastinal reflection, (2) the caudoventral
mediastinalreflection,and (3) the vena cavalmediastinalreflection,
or the plica vena cava.
On a ventrodorsal or dorsoventral radiograph, the cranioventral
mediastinal reflection appears as a curving radiopaque line, with
the concavesurface on the patient's right, extending from approxi-
mately T1 or T2 to the region of the main pulmonary artery (see
Figs. 30-4 and 30-5). This reflection is causedby extensionof the
right cranial lobe acrossthe midline, pushing the mediastinum to

Figure 30-3. Left atera radiographof the thorax of a normaldog.

The opacitvventralto the trachea\white arrowheadsindicateventral
m a r g i no f o p a c i t y )i s pa r t o f th e cr a n ia m l e d ia stin u mAlth
. o ughthere
ar e s e v e r a d l i f f e r e n to r g a n sin th is p a r t o f th e m e d ia stin u m ( e.9.,l eft
subclavian a r t e r y b r a ch io ce p h a lictr u n k,a n d cr a n ia vel n a ca v a),they
c a n n o tb e d i s c e r n e dbe ca u seth e y a r e in co n ta ctwith e a ch o therand
t h e r e i s i n s u f f i c i e nf ta t to p r o vid eco n tr a st.T h e m e d ia stin u m extends
f ro m t h e v e r t e b r a ve e ntr a lly to th e ste r n e b r a eb,u t it is m o st r a di opaque
im m e d i a t e lvye n t r a tl o th e tr a ch e ab e ca u seits th r ckn e ssis g r eatesti n
t h i s l o c a t i o n( s e e F i g .3 0 - 4 ) . No te a lso th e cr a n io ve n tr aml e di asti nal
reflection(blackarrows)between the craniaiportionof the left crania
lobe /L/ and the right craniallobe /B/ (see Fig.30-4).
378 NE CKA ND T H OR AX -C OMP AN IO A
NN IMA LS

Figure 30-4. Transversecomputedtomographic(CT)imageof the caninethoraxat

the level of the second thoracicvertebra.Note the greaterthicknessof the dorsal
mediastinum.This accounts for the ooacitv seen ventral to the trachea in lateral
thoracicradiographsisee Fig.30-3). Note the vesselsventralto the trachea(t. There
i s i nsuffi ci ent
fat for thesevessel sto be seeni n radi ographs, but the s uperi ori nherent
contrastof CT allows them to be identified,Note also the cranioventralmediastinal
refl ecti on; the ventralmedi asti num i s bei ngpushedto the l eft by the ri ghtc rani all ung
lobe (R).

the left (seeFig. 30- ). The thicknessofthe cranioventralmediasti-
nal reflection is affected by the amount of fat it contains. On the
lateral view, the cranioventral mediastinal reflection and the margin
of the right cranial lobe may frequently be identified immediately
cranial to the heart (seeFig. 30-3). The cranioventralmediastinal
reflection is not visible in every thoracic radiograph. The thymus
lies in the cranioventral mediastinal reflection, and the thymus can
sometimes be identified in ventrodorsai or dorsoventral radio-
graphs of young animals. The thymus is not as readily seen on
lateral thoracic radiographs (Fig. 30-7). In lateral projections of
the thorax made before the thvmus involutes, however, the thvmus
may silhouettewith and obscurethe cranial margin of the heart.
The caudoventral mediastinal reflection is seen only on ventro-
dorsal or dorsoventral radiographs; it cannot be seen in lateral
projections. It is created by extension of the accessorylobe (a
lobe of the right lung) across the midline, thereby pushing the

Figure 30-5. Ventrodorsalradiographof the cranialaspectof the thorax of a normal

dog. The crani almedi asti numi s superi mposed on the crani alaspec tof the thorac i c
spine; it is relativelyindistinct.As an approximation,the width of the normal cranial
mediastinumin ventrodorsalor dorsoventralradiographsshould not be greater than
twice the diameterof the vertebrae.Note the mediastinalreflectionbetween the right
craniallobe and the cranialpart of the left craniallobe (arrows).See Figure30-3 for the
appearanceof this reflectionin the lateralview and Figure30-4 for an lllustrationof the
ri ghtl ung pushi ngthe medi asti numto the l eft.
 The Medi ast inum 37f J

1l::;]r,,.t.'Q

itll:rrlet,...

'l:illiirl.llll

iiliut. ::ir:11..
lrr.i.q
'':it*.

"]];:iilllll
i':iliiiilll

Figure 30-6, Dorsoventralradiograph

of the cranialaspectof the thoraxof
an obesedog.Thecranial mediastinum contains a largeamountof fat and
appearswiderthantwicethe diameterof the vertebrae (arrows).
Careshould
betakento avoidmisinterpreting
a widemediastrnum in anooeseantmat asa
mediastinal
mass.

mediastinum to the left. The caudoventralmediastinal reflection Figure 3O-8, Ventrodorsal

appearsas a relativelystraight radiopaque line in the caudal left
hemithorax, extending from the region of tl-recardiac apex in a
caudolateraldirection toward the gastric fundus (Fig. 30-S). The
caudoventralmediastinalreflection has been incorrectly identified
as the sternopericardiacligament (also called the cardiophrenicor
phrenicopericardiac ligament),but the sternopericardiacligament,
which is a continuation of the apex of the fibrous pericardium, is
not visible radiographically.oThe thickness of the caudoventral
mediastinal reflection depends on the amount of fat it contains
radiographof the caudalthoraxof a normaidog.
Thecaudoventral
mediastinal
refectionis visble /arrowl.
(Fig. 30-9), and in individual animals,this may changeappreciably
as body staturechanges.The caudoventraimediastinil refLction ii
not visible on every ventrodorsal or dorsoventralthoracic radio_
grapn.
The caudal vena caval mediastinal reflection, or plica vena cava,
is not visible as a distinct structure in radiographi of the thorax,

Figure 30-7. LaIerd (A)and ventrodorsa1Blradiographs of the thoraxof a young

d o g .T h e t h y m u sha sn o t ln vo lu te dIn . th e ve n tr o d o r sa lview (B ),the thvmusapoears
a s a s a i l - s h a p eodp a citycr a n iaal n dto th e le ft o f th e ca r d iacbase.In the l ateralvi ew ,
t h e t h y m u sp r o d u ce sa lin e a rr e g io no f so ft tissu eo p a cityj ust crani alto the heart.
T h e t h y m u sm a y no t a lwa ysb e visr b lein th e la te r ave l w in dogs i n w hi ch i t i s seen
i n t ' t e v e n L r o o o rsa
p r oe ct o n .
38O NE CKA ND TH O R AX -C OMP AN IO A
NN IMA LS

Figure 30-9, Ventrodorsalradiographof the caudalaspect

of the thorax of an obese dog. Fat has accumul atedi n the
caudoventralmedi asti num,resul ti ngi n i ncreas edthi c k nes s .
C omparei ts appearancei n thi s radi ographw i th that i n Fi gure
30-8.

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.

There are four general classificationsof mediastinal abnormalities:

(1) mediastinalshift, (2) mediastinalmasses,(3) mediastinalfluid,
and (4) pneumomediastinum.
Mediastinal shift
Mediastinal shift occurs as a result of a unilateral decreasein lung
volume (ipsilateral shift), a unilateral increase in lung volume
(contralateralshift), or the presenceof an intrathoracicmass (con-
tralateral shift). Mediastinal shifts are not readily apparent on
lateral radiographs.Therefore,the mediastinalposition should be
assessed carefully on ventrodorsal or dorsoventral radiographs. The
Mediastinal masses
Mediastinal massesare common, and their radiographic appear-
ance is often similar. Ventrodorsal or dorsoventral projections are
more useful than the lateral view in deciding whether an abnormal
mass is located in the mediastinum versus the lung. Mediastinal
location of a radiographically detectableintrathoracic mass should
be consideredif (1) the mass lies on or adiacent to the midline
(Fig. 30-11), (2) the mass is in a position consistentwith one of
the three previouslydescribedmediastinalreflections(seeFig. 30-
7), or (3) the mass deviatesa mediastinalstructure. Lunq masses

'l
j

"r ' .
-r I
;' 6 -"ll
_

Figure 30-1O. Ventrodorsalradiographof a dog with mediastinalshift. The heart and

caudoventral mediastinalreflection(solidwhite arrow)aredisplacedto the left becauseof
decreasedvolume of the left caudallung lobe. The right middle lobe is collapsed/open
black anows), and there is alveolardisease in the left caudal lobe. The caudoventral
refl ecti ondoes not appearas a di sti nctl i neas seen i n Fi gure3 0-8. B ec aus e
medi asti nal
of the increasedopacityof the left caudallobe,the lobe silhouetteswith the reflection.
 The Mediast inum 381

Figure 30-11, Laleral (A) and ventrodorsaliBl thoracic radiographsof a dog

w i t h l y m p h osa r co m A, a . A la r g em a ss is visib lecr a ni alto the heart.A l thoughi ts
p o s i t i o ni s c o n siste nwith
t m e d ia stin aml a ss,a n d th ere i s dorsaldi spl acement of
t h e t r a c h e ath, e e xa ctp o sitio no f th e m a ssca n n o tb e determi ned from the l ateral
v i e w . B , T h e m a ssis ce n te r e do n th e m id lin esu
, g g esti ng a medi asti nal
l ocati on.

can often be distinguishedfrom mediastinalmassesbecausethey
are usually positioned lateral to the mediastinum (Fig. 30-12).
There are instances, however, when mediastinal massesprotrude
Iaterally and are surrounded by sufficient lung (which provides
contrast) to be mistakenfor a lung mass.
Cranial mediastinalmassesoften causeelevationof the trachea.
Elevation of the trachea may also result from a large volume of
fluid in the pleural space(Fig. 30-13). With a large-volumepleural
effusion, tracheal elevation results from displacement of lungs as
they float in the pleural fluid.' Tiacheal elevation does not occur
when only a small volume of fluid is present in the pleural space
unless a mediastinal mass is also present. If pleural effusion is
present, definitive identification of a concurrent mediastinal mass
is usually not possible unless the mass compressesthe trachea;
pleural fluid alone does not result in tracheal compression.If
pleural fluid obscuresthe mediastinum and a mediastinal mass is
being considered,removing the fluid and repeating the radiographs
may be helpful. Additional radiographs made with a horizontally
directed x-ray beam may also be helpful. These horizontal-beam
radiographs take advantage of gravity, which causespleural fluid
to migrate away from the area of the suspectedmediastinal mass.
Ultrasonographic examination is also of value in assessingthe
cranioventralmediastinum for the presenceof a mass,and ultra-
sound-guided aspiration or biopsy facilitatesmaking a definitive
diagnosis.6,?The specific location of a mass lesion within the
mediastinum also provides helpful information in the formulation
of a differential diagnosis.Causesof mediastinalmassesare listed
in Table 30-2.
Mediastinallymphadenopathyis one of the most common causes
of a mediastinal mass, and lymphadenopathy can be associated

Figure 3O-12. Ventrodorsalradiographof the thorax of a

do g .T h e r ei s a l a r g ema ss in th e r ig h tcr a n iahl e m ith o r a x. The
pr o b a b i l i t o
y f s u c h a m a ss b e in g in th e m e d ia stin u mis lo w
be c a u s ei 1 ) t h e m a s sis lo ca te dla te r ato l th e m e d ia stin u m( ,2)
it i s n o t i n a p o s i t i o no f o n e o f th e m e d ia stin ar e
l fle ctio n s,
and
{3 ) n o n o r m a lm e d i a s tin aolr g a n sa r e d isp la ce d( th etr a ch e ais
no r m a l l yo n t h e r i g h t in th e cr a n ia lth o r a x) .Dia g n o siswa s
pr i m a r yl u n gt u m o r i n th e r ig h tcr a n ialu
l n glo b e .
TA2 NE CKA ND T H OR AX -C OMP AN IO AN
N IM ALS

Figure 3O-13. Lateralradiographof the thoraxof a cat with

pleuraleffusion.The tracheais displaceddorsally,but the pres-
ence of a medi asti nal mass cannotbe confi rmedbec aus e(1)
pl euralfl ui d may be accompani ed by trachealel ev ati onw hen
no medi asti nal mass i s present,(2) a mass ca nnotbe s een,
and (3)therei s no compressi on of the trachea.

with a variety of diseases(Table 30-3). Alternatively, there are
neoplastic and inflammatory diseasesthat would seem to logically
involve the mediastinal lymph nodes, but do not typically do so
(Table30- ). The major groupingsof lymph nodesin the mediasti-
num are discussedin the following paragraphs.8'e
The cranial mediastinal lymph nodes vary in number and size.
Most of them lie along the cranial vena cava and brachiocephalic,
1eft subclavian, and costocervicalarteries and are therefore located
in the cranial mediastinum, just ventral to the trachea. Afferent
lymphatics come from the muscles of the neck, thorax and abdo-
men, scapula,last six cervical vertebrae,thoracic vertebrae,ribs,
trachea,esophagus,thyroid, thymus, mediastinum, costal pleura,
heart, and aorta. The cranial mediastinal lymph nodes also receive
efferent lymphatics from the intercostal, sternal, middle, and caudal
deep cervical, tracheobronchial, and pulmonary lymph nodes. Ef-
ferent channels from the tracheobronchial lymph nodes drain into
either the thoracic duct or the left tracheal trunk, or both. Enlarge-
ment of the cranial mediastinal lymph nodes results in a visible
mass in the cranial mediastinum that often createsa mass effect in
the cranioventral thorax characterizedby elevation of the trachea
on the lateral view and widening of the cranial mediastinum on
the ventrodorsalview (Fig. 30-1a). Radiographicidentification of
enlarged mediastinal lymph nodes in dogs with lymphosarcoma
has been identified as a negative prognostic factor.ro
The sternal lymph node is usually represented by a single node
on each side in the dog, and a single node in the cat. In the dog,
there is occasionally only a single median node. The sternal node
Iies in the ventral mediastinum, immediately cranial to the
transversusthoracis muscle and medial to the secondcostal carti-
lage or second interchondral space;it is cranioventral to the inter-
nal thoracic blood vessels.The afferent lvmphatics of the sternal
node lie under the transversus thoracis in the fat between this
muscle and the dorsal surfacesof the sternal ends of the costal
cartilages. They arise in the abdominal wall and perforate the
diaphragm near the middle of the costal arch. Afierent vessels
receivetributaries from the ribs, sternum, serous membranes, thy-
mus, adjacent muscles,and mammary glands. Sternal lymphade-
nopathy appearsas an isolated soft-tissueopacity dorsal to the
region of the second sternebra and is best seen on the lateral
projection, although occasionally there is a sufficiently large mass
for the enlargement to be seen on the ventrodorsal view (Figs.
30-15 and 30-16).
The tracheobronchiallymph nodes are known as the right, left,
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

Figurc 30-14. LaIerc (A) and ventrodorsa 1Blthoracicradiographsof a cat with
e n l a r g e m e not f th e cr a n ia m l p h n o d e s.T herei s a l arge,homogeneous
l e d ia stin alym
soft-tissue m a ss in th e cr a n io ve n tr ma l e d ia stin u mT.h e massi s el evati ngthe trachea
a n d d i s p a c i n gth e cr a n ia u n g o b e s la te r a llya n d caudal l y.In cats, i t i s vi rtual l y
i m p o s s i b lteo d istin g u ish
b e twe e ne n la r g e m e notf th e crani almedi astl nal
a n d t h e t h y m u s.Dia g n o sis wa s cr a n iam l e d ia stin alym phosarcoma.
nodes lie on the lateral side of their respectivebronchus and also
contact the trachea.The right node is ventral to the azygousvein,
the left ventral to the aorta. The middle tracheobronchial lymph
node is the largestof the group. It is in the form of a V and lies
in the angle formed by the origin of the primary bronchi from the
trachea.Afferent vesselsto the tracheobronchiallymph nodescome
from the lungs and bronchi primarily, but they also come from
the thoracic parts of the aorta, esophagus,trachea,heart, mediasti-
num, and diaphragm. Enlargement of the tracheobronchial lymph
nodes resultsin visualizationof a soft-tissueopacity in the region
of the tracheal bifurcation on the lateral view (see Fig. 30-15).
Enlargementof the tracheobronchiallymph nodes is usually more
apparent on the lateral than on the ventrodorsalor dorsoventral
projection.Lateraldivergenceor separationof the principal bronchi
may be apparent on the ventrodorsalview (Fig.30-17; see also
Fig. 30-15). The easewith which enlargedtracheobronchiallymph
nodes are seen on the lateral view deoends on their size and
the amount of adjacent lung opacity. In instancesin which the
lymphadenopathy exists with lung disease,the opacity from the
lung diseasemay make the enlarged tracheobronchial lymph nodes
more difficult to identi0' becauseof the silhouettesign (Fig. 30-18).
On the lateral view, enlarged tracheobronchial lymph nodes may
result in elevation or depression of the tracheal bifurcation; in
some dogs,no changein position of the trachealbifurcation results
from tracheobronchial lymphadenopathy. Enlarged tracheobron-
chial lymph nodes that result in elevation of the tracheal bifurca-
tion may be confused radiographically with an enlargedleft atrium.
Table 3O4. Diseases not typically associated with
mediastinal lymphadenopathy
Mam m ar y adenoc ar c inom a
Metastaticlung neoplasia
Bact er ialpneum onia
Pyothorax
Th or ac icwall t um or s , e. 9. ,r ib t um or s
The Mediast inum 383
ymph nodes
Mediastinal fluid
Free mediastinal fluid is usually of soft-tissue opacity; therefore, it
may appear radiographicallyas a mediastinalmass, or as cardio-
megaly if it collects around the heart, or both (Fig. 30-19). If
mediastinalfluid is a radiographicconsideration,its presencemay
be detectedby horizontal-beamradiography (unlessit is trapped
or loculated) or ultrasonography.The more common causesof
mediastinalfluid include feline infectious peritonitis, trauma, co-
agulopathy, and esophagealperforation. Mediastinal fluid may also
accumulatesecondaryto an underlying mass.
Pneumomediastinum
Pneumomediastinumis free gas in the mediastinum. Mediastinal
gas provides excellent radiographic contrast, thereby resulting in
enhancedvisualizationof mediastinalorgans (Fig. 30-20). If only
a small amount of mediastinal gas is present, the only apparent
abnormality may be patchy regions of radiolucency in the cranial
mediastinum (seeFigs.30-13 and 30-16). The sizeof the mediasti-
num is not greatly increasedwhen pneumomediastinum is present.
Therefore, pneumomediastinum is not readily seenon ventrodorsal
or dorsoventral radiographs (Fig. 30-21). Pneumomediastinum
may progress to pneumothorax if mediastinal pressure results in
tearing of mediastinal pleura, thus establishing communication
between the mediastinum and the pleural space.Dyspnea is usually
not seen with pneumomediastinum unless it progressesto pneu-
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;
see Fig. 30-2I). Alternatively, gas in the retroperitoneal space or
fascial planes of the neck may diffuse into the mediastinum.
There are six causes of pneumomediastinum, listed here in
decreasingorder of likelihood:
l. Air escapinginto the lung interstitium from sites of alveolar
rupture can diffuse in a retrograde direction in loose connecti\-e
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 .

Figure 30-16. Lateralthoracicradiographof a cat with lymphosarcoma. There is a

w el l defi nedregi onof i ncreased
opaci tydorsalto the thi rdand fourthst ernebrae. Thi s
opaci tyrepresents an enl argedsternall ymphnode.A ddi ti onal l gas
y, i s p res entv entral
to the trachea,w hi ch i s consi stentw i th pneumomedi asti numj thi s li k el yoc c urred
secondary to trachealpuncturew hen bl oodw as bei ngcol l ectedfrom th e j ugul arv ei n.
 The Medi ast inum 385

Figure 3O-17, lliustrationof the appearanceof the shape of the pnncipal

br o n c h i n t h e c a u d a l o b e sin a ve n tr o d o r sar al d io g r a pin
h th e normalstate //eftl
and when there is a mass present between |hem (middle and right). Ihe
pr e s e n c eo f a m a s s ,su cha s a n e n la r g e dle ft a tr u m a n d a r e gi onall ymphnode,
be t w e e nt h e p r i n c i p abi r o n ch im a y r e sut r n th e p r in cip abl r onch assumi nga
curvedappearance(middle)or beingdisplacedlateraly (right)or both.

Figure 30-18. Lateralview of the thorax of a dog with

l ymphosarcoma.There i s an i l l -defi nedreg i onof i nc reas ed
opacityaroundthe trachealbifurcationbecauseof tracheobron-
chi al l ymphadenopathy. l vl argi nsof rhe l ymphadenopathy are
di ffi cul to
t rdenti fybecausethere i s al sol ymphomai nfi l tratei n
the l ung i ntersti ti um
that si l houettes w i th the enl argedl y mph
nodes.D efi ni ti vei denti fi cati on
of enl argedtrac heobronc hi al
l ymphnodesi s more di ffi cul tw hen l ung di seas ei s al s o pres -
ent.
386 NE CKA ND TH O R AX -C OMP AN IO A
NN IMA LS

Figure 3O-19. larcral (A), ventrodorsal /B/, and hori-

zontal-beamventrodorsal/C/ views of the thorax of a
cat w i th free medi asti nal fl ui d.A , The cardi acsi l houette
i s obscuredby homogeneous opaci fi cati on
of the ventral
thorax. B , The crani almedi asti numi s w i de, and the
cardi acsi l houettei s enl arged w i th an unusualrectangu-
,
lar-appearing right margin. C, The heart is clearlyseen
i n the mi ddl eof the thorax,and the caudalmedi asti num
is increasedin width owing to caudalgravitationof the
free medi asti nal fl ui d. D i agnosi sw as fel i ne i nfecti ous
peri toni ti s,(FromThral lD E , LosonskyJM: D yspneai n
the cat: l l . R adi ographiaspects
c of i ntrathoracicauses
c
i nvol vi ngthe medi asti num. Fel i neP ract8.47,1978.J
 The Mediastinum 3,87

Figure 3O-2O. Lateralview of the thorax of a cat with

p n e u m o m e d i a s t i n uT mh. e r eis e n h a n ce dvisu a liza tioonf th e
e s o p h a g u sa, d v e n titiasu l r fa ceo f th e tr a ch e a ,cr a n ia ive n a
c a v a ,a z y g o u sv e i n , a n d m a jo r b r a n ch e so f th e a o r tica r ch 'iriill)..iihl
b e c a u s eo f c o n t r a stp r o vid e db y fr e e m e d ia stin agl a s. T h e
l u n g i s a l s oo p a c i f i edca u d a lly.( Co u r te sy
o f Dr . M a r y M a h a f-
f e y , U n i v e r s i toy f G e o r g iaAth
, e n s,GA.)

situation occurs commonly after trauma and also occurs after
iatrogenicpulmonary hyperinflation during anesthesiaor resuscita-
tion.12Pneumothorax is not present when pneumomediastinum
resultsfrom this mechanismunlessthe pulmonary pleura becomes
torn or the mediastinalair accumulation resultsin perforation of
mediastinalpleura.
2. Caudal extension of gas in neck fascialplanes into the medias-
tinum may occur. Gas in the neck is a common sequel to neck or
oral cavity trauma; it also may result from tracheal or esophageal
rupture.
3. A hole in the wall of the trachea may occur as a result of
trauma or, less likely, erosion from neoplasiaor inflammation. If
the hole is intrathoracic,air entersthe mediastinum directly.If the
hole is in the neck, air may dissectalong the tracheathrough the
thoracic inlet into the mediastinum. Pneumomediastinum may
occur following jugular venipuncture if the needle inadvertently
punctures the trachea.In cattle and horses,pneumomediastinum
is frequently seen following transtrachealaspiration procedures.
Tlacheal rupture in anesthetizedcats associatedwith overdistention
of the endotrachealtube cuff is a noteworthy cause of pneu-
momediastinum.r3, raThere may be a tendencyfor cuff overdisten-
tion during procedures such as dental prophylaxis wherein aspira-

Figure 3O-21. Ventrodorsalview of a cat with pneumomediastinum. Note the inabilityto

i d e n t i f yt h e m e d i a s tin agla s.T h e o p a citycr a n io la te rto
a l th e cardi acbaseon the cat'sl eft si de
i s t h e t h y m u s ,w h i c h is d isp la ce d la te r a lly
b y th e e m p h yse matous Therei s gas
medi asti num.
b e t w e e nt h e r i o h ts ca o u laa n d th e th o r a cicwa ll.
388 NE CKA ND TH O R AX -C OMP AN IO A
NN IMA LS
tion is considered likely. Cuff overdistention may result in rupture
of the trachealis muscle at the point of attachment to the tracheal
cartilages. Tiacheal rupture may occur at a modest cuff volume
and may not be immediately apparent to the anesthetist.Develop-
ment of subcutaneousemphysemais concurrent with pneumome-
diastinum and if observed should alert the anesthetist to this
potentially fatal complication of anesthesia.
4. Trauma, neoplasia, or inflammation may lead to esophageal
perforation.
5. Retroperitoneal gas may extend cranially into the mediasti-
num.
6. A gas-producingorganism in the mediastinum is a very un-
likely cause.
References
1. Schummer A, Nickel R, Sack W: The Viscera of the Domestic Mammals, 2nd ed.
New York, Springer-Verlag, 1979.
Figure 30-23
Figure 30-22. Abdominal radiographof the same cat as
that i n Fi gure30-20. There i s a l argeamount of gas i n the
retroperi tonealspaceas a resui tof di ssecti ono f medi as ti nal
gas caudal l ythroughthe aorti chi atus.(C ourte s yof D r. Mary
Mahaffey,U ni versi ty
of Georgi a,A thens,GA .)
2. Evans HE: The respiratory system. In Evans HE (ed): Miller's Anatomy of the
Dog, 3rd ed. Philadelphia, WB Saunders, 1993.
3. Kern DA, Carrig CB, Martin RA: Radiographic evaluation ofinduced pneumotho-
rax in the dog. Vet Radiol Ultrasound 35:411,1994.
4. Burk RL: Radiographic definition of the phrenicopericardiac ligament. J Am Vet
Radiol Soc 17:216,1976.
5. Snyder PS, Sato T, Atkins CE: The utility of thoracic radiographic measurement
for the detection of cardiomegaly in cats with pleural effusion. Vet Radiol 3l:89, 1990.
6. Konde LJ, Spaulding KA; Sonographic evaluation of the cranial mediastinum in
small animals. Vet Radiol 32:178, 1991.
7. Reichle JK, Wisner ER; Non-cardiac thoracic ultrasound in 75 feline and canine
patients.Vet Radiol Ultrasound 41:154,2000.
8. Bezuidenhout AJ: The lymphatic system. In Evans HE (ed): Miller's Anatomy of
the Dog, 3rd ed. Philadelphia, WB Saunders, 1993.
9. Tompkins MB: Lymphoid system. In Husdon LC, Hamilton WP (eds): Atlas of
Feline Anatomy for Veterinarians. Philadelphia, WB Saunders, 1993.
10. Starrak GS, Berry CR, Page RL, et al: Correlation between thoracic radiographic

Figurc 30-24
changes and remission/survival in 270 dogs with lymphosarcoma. Vet Radiol Ultra-
sound 38:411,1997.
11. Macklin CC: Transport ofair along sheathsofpulmonic blood vesselsfrom alveoli
to mediastinum:Clinical implications.Arch Intern Med 64:913,1939.
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.
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.
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.
n Ouestions
l. Which of the following statementsis false?
A. The mediastinum is a closedsoace.
B. The mediastinal pleura is an ineffective barrier to spread of
diseasefrom one pleurai cavity to another.
C. The cranial mediastinum appears most opaque in lateral
radiographs just ventral to the trachea becauseits thickness
is greatestat this level.
D. In normal dogs, the width of the mediastinum in ventro-
dorsal radiographs should be less than approximately two
times the thickness of the spine.
2. Which two of the following mediastinal reflections are visible
in most normal canine thoracic radiographs?
A. Cranioventral
B. Caudoventral
C. Caval
D. Plica vena cava
3. Why is it easierto determine if an intrathoracic mass is located
in the mediastinum from ventrodorsal or dorsoventral radiographs
rather than from lateral radiographs?
The Mediastinum 389
4. Based on the following lateral and ventrodorsal feline thoracic
radiographs (Fig. 30-23), list as many roentgen signs as you can
indicating that the opacity seen in the cranial thorax is a mediasti-
nal mass.
5. Basedon the following lateral canine thoracic radiograph (Fig.
30-24), the most likely diagnosisis:
A. Diaphragmatichernra.
B. Pleural effusion.
C. Pneumomediastinum.
D. Cranial mediastinal lymphadenopathy.
6. A dog with a ruptured bowel is given barium. The barium
extravasatesinto the peritoneal cavity. Immediate abdominal sur-
gery is successfulin repairing the rupture. A thoracic radiograph
is made 2 days later becauseof a cough. Which mediastinal lymph
node would be the most likely to have evidence of the previous
barium extravasation, and what would the radiographic changes
D e(
7. Name two imaging techniquesthat can be used to differentiate
between mediastinal fluid and a mediastinal mass.
8. What is the most common causeof pneumomediastinum?
9. True or False.Pneumothorax readily progressesto pneu-
momediastinum.
10. True or False. Enlargement of the tracheobronchial lymph
nodes may cause elevation of the tracheal bifurcation, depression
ofthe tracheal bifurcation, or no changein tracheal bifurcation po-
sition.
Answers begin on page 727,
ffi CHAPTER

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.

Normal radiographic I Pleural effusion

I
I appearanceof pleura and Fluid in the pleural spaceis called.pleural effusion.This fluid can
be exudate,transudate,or modilied transudate(Table 31-1). The
I pleural thickening nature of the radiographic changesassociatedwith pieurai fluid
depends on the volume of fluid, the position of the animal in
Normal pleura is usually not visible radiographically.Pulmonary
relation to the x-ray beam, the distribution of the fluid, and
pleura outside of interlobar fissures cannot be seen becauseit
whether the fluid is free or loculated.
siihouetteswith adjacentsoft tissue.Pulmonary pleura within in-
tralobar lissuresis surrounded by intrapulmonary air, which pro-
vides contrast, but the pleura is so thin that it generally does
not absorb a sufficient number of x-ravs to Droducea detectable
radiographicopacity.

N4ED]AST NUIV
COSTAL PARIEIAL PLEURA
[,IEDIASTINALPARIETAL PLEURA

A DIAPHRAGMATIC PARIETAL PLEURA

COSTAL PARIETAL PL E URA

PLEURA -
PULt\,4ONARY
MEDI AST ADHEREN-I TO LUNG

PLEURAL SPACE

MEDIASTINAL PARIETAL PLEURA

B
Figure 3l-1. Drawingsof the thorax in dorsal1,4./ and transverse1Blplanes Figurc 31-2. Ventrodorsalthoracicradiographof a dog in which interlobar
o f th e p le u r a la
il us t r a t i n gt h e r e l a t i o n s hip l ye r s.A, No te th e co n ti nui tyof the fi ssures/arow s./are vi sl bl e.Thesefi ssuresare thi ckerthan normaland may
p a r tso f th e p a r r e tapl e u r a .{Lungshave
c os t a l ,m e d i a s t i n aal ,n d d i a p h r a g m a tic be due to ether pl euralthi ckeni ngor a smaI pl euraleffusi on.In thi s dog,
not b e e n i n c l u d e dn A . ) B , No te h o w th e m e d ia stin aplle u r ais r ef ectedonto pl euraleffusi onw as not i denti fi ed
w hen the thoraxw as radi ographed
us i nga
t he lu n ga s p u m o n a r yp e u r a .No tea so th a tth e p le u r asp l a cels n o t contl nuous hori zonta l y di rectedx-ray beam. Thus, the most common ca us e of thes e
wit h t h e m e d l a s t i n u mH. , h e a r t;L , lu n g ;T , tr a ch e a . fl ssure i nesi s peuralthl ckeni ng.

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

E, exudate: M, modified transudate; T, transudate.

cause.Free pleural fluid distributes itself according to gravity and

Free pleural effusion
The typical radiographic changesassociatedwith free pleural effu-
sion are the same, regardlessof fluid type, becauseneither the
distribution of free oleural fluid nor its ooacitv is related to the
the ability of the lung to expand, that is, lung compliance. Thus,
the appearance of pleural effusion in lateral, ventrodorsal, and
dorsoventral radiographs made with a vertically directed x-ray
beam is different.' Radiographic signs of free pleural fluid are listed
in Thble 31-2.

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
lntdrlobar fissures
The thickness and number of interlobar fissures seen with pleural
fluid vary according to the amount of fluid and the relative position
of the patient and the x-ray beam (Fig. 31-3). Approximately 100
mL of fluid must be present in the pieural space of a medium-
sizeddog before widened interlobar fissuresbecomevisible.'Visu-
alization of widened interlobar fissurescausedby accumulatedfluid
results when the x-ray beam strikes the fluid-containing fissure
tangentially. Some fluid-containing fissures may not be seen be-
causetheir relationship to the x-ray beam is not tangential.
With small effusions, interlobar fissures are more likely to be
seen on ventrodorsal rather than dorsoventral radiographs. This is
becausewhen the patient is in ventral recumbency,small effusions
collect dorsal to the sternum and do not enter fissures or increase
overall thoracic radiopacity to a sufficient degree to be seen.'zIn
lateral radiographs, small effusions usually result in visualization
of fissures.As the volume of fluid increases,the number of interlo-
bar fissuresseen as well as their thickness increases(Figs. 31-4
ano JI-)J.
Horizontal-beam radiography
It may not be possible to identifu small effusions on survey radio-
graphs ifthe x-ray beam fails to strike a fluid accumulation tangen-
tially. To enhance fluid detection, a horizontally directed x-ray
beam may be used to ensure a tangential relationship between the
x-ray beam and the fluid collection. If free pleural fluid is present,
it gravitatesdependently to the site where the x-ray beam intersects
it tangentially(Fig. 31-6). A sharply demarcated,straight fluid line
is not seen in patients with pleural fluid when radiographed with
a horizontal x-ray beam becausethe configuration of the fluid is
altered by the adjacent lung, which retracts becauseof elastic recoil.
Sharp fluid lines are seen in horizontal-beam radiographs only
when there is a free fluid-free air interface. Horizontal-beam radio-
graphs may be useful in distinguishing between pleural fluid and
.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.)
an intrathoracicmassas the causeofan intrathoracicopacity (Figs.
31-7 and 3i-B).
Retraction of lung margin
Pleural fluid results in retraction of the pulmonary pleurai surface
of the lung away from the parietal pleural surface of the thoracic
wall or diaphragm. The magnitude of this separation depends on
the volume of fluid present and the compliance of the lung. With
normal lungs or with lungs of uniformly decreasedcompliance,
retraction of the lungs away from the thoracic wall is uniform, and
the degree of collapse is a function of fluid volume. \A/hen only a
portion of the total lung volume has decreasedcompliance,that
part of the lung retractslessthan normal lung. Thus, when nonuni-
form retraction of lung is seen in patients with pleural effusion,
underlying pulmonary disease that has altered lung compliance
should be considered.
Retraction of lung from the thoracic wall can be seen on lateral,
dorsoventral,and ventrodorsalradiographs (see Fig. 31-5). With
pleural effusion, fluid surrounds the lung, but the fluid is most
apparent radiographically when the x-ray beam is tangential to the
fluid (Fig. 31-9). Therefore,more pleural fluid is typically present
than one would predict based on the severityof the radiographic
cnanges.
Retrosternal opacification
In lateral radiographs, free pleural fluid often results in an increased
radiopacitydorsal to the sternum (seeFigs.31-5C and 31-7). This
finding is the result of fluid having collected in the ventral thorax,
probably layeredagainst the ventral mediastinum in the nondepen-
dent hemithorax. If the patient has a unilateral effusion and the
fluid is in the dependent hemithorax, this opacity may not be
visible becausethere is no fluid in the nondependenthemithorax
to layer againstthe mediastinum. The margin of the retrosternal
opacity created by pleural effusion usually appears scalloped be-
 The PleuralSoace 393

Figure 31-5. Ventrodorsal /A/, dorsoventral /B/,

and left lateral/C/views of the thoraxof a dog with
a l argevol umeof fl ui di n the pl euralspace.A , There
are numerousi nterl obar fi ssures,and the r i ghtc au-
dal lobe is separatedfrom the thoracicwall by an
area of soft-tissueopacitv.The cardiacsilhouetteis
vi si bl e.N otethe appearance of the costalc arti l ages ;
they shoul dnot be mi stakenfor i nterl obar fi s s ures ,
The concaveaspectof costalcartilagesfaces crani-
ally, whereas the concaveaspect of interlobarfis-
suresfacescaudal l y. 8, Interl obar fi ssure sand l ung
di spl acement aw ayfrom the thoraci cw al l are agai n
evi dent.The cardi acsi l houettei s not vi s i bl e,the
di aphragmi s obscured,and the overal lra di opac i tv
of the thoraxi s i ncreased (seeFi g.31-10).C There
are i nterl obar fi ssures,the cardi acsi l houettei s par-
ti al l yobscuredby surroundi ng fl ui d,and th e ov eral l
radi opaci ty of the thoraxi s i ncreased.l n addi ti on,
there is an area of radiopacityjust dorsai to the
sternum,the margi nsof w hi ch are scal l oped ow i ng
to fl ui daccumui ati on i n the ventralthorax .
394 NE CKA ND TH OR AX -C OMP AN IOAN
N IM ALS

+X-RAY BEAM Figure 31-6. The demonstrationof pleuralfluid by horizontal-beam radiogra-

phy. Fluidis representedby the gray stippledareas.Fluidin the nondependent
hemi thoraxl ayersagai nstthe medi asti num (assumi ng
the medi a s ti numi s c om-
pl ete).Thi sfl ui d (nondependentsi de)i s not radi ographi caldete
l y c tabl e.
Fl ui di n
the dependenthemi thoraxgravi tatesto the area betw een the l ung and the
thoraci cw al l w here the hori zontal ldtrected
y x-raybeam stri kesi t tangentl al l y .
M. medi asti num.

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

Figure 31-8. Lateral (A), ventrodorsal /B/, and horizontal-

beam ventrodorsal/C,),(cat supported in upright position)
views of the thorax of a cat. A, fhere is opacificationof the
c r a n i a tl h o r a xa n d s lig h tco m p r e ssio n o f th e tr a ch e aa t th e
th o r a c i ci n l e t .T h e h e a r tis o b scu r esu g g e stin g th e r e is a d ja-
c e n t f l u i d . C i r c u l a rra d io lu ce n cieasr e a ir b u b b le sr e su lting
fr o m p r e v i o u st h o r aco ce n te sis; a sm a llvo lu m eo f flu id wa s
removedfor cytology.B, The craniallylocatedopacityis visi-
b l e a n d i s o n t h e m id lin e th ; e sefin d in g sa r e co n slste nwith
t
a m e d i a s t i n aml a s s .To r u leo u t th e o o ssib ilitv th a t th e cr a n ial
th o r a c i co p a c i t yw a s flu id a n d n o t a m a ss,h o we ve r a , hori-
zontal-beamradiographwas made. C, The opacity has not
moved, suggestingthat it is a mass.The caudoventralmedi-
a s t i n a rl e f l e c t i o nh a s in cr e a se d
sig n ifica n tly
in th ickn e ss; th is
i s c o n s i s t e nw l idth a t h a s g r a vi-
t i t h c o e xistin gm e d ia stin aflu
ta t e dc a L d a l l yT.h e r eis n o e vid e n ceo f p le u r ael ' fu sio n .
396 NE CKA ND TH O R AX -C OMP AN IO AN
N IM ALS
X -R A Y BE AM
* radiographs,pleural fluid doesnot as readily obscurethe heart and
\::\
t,,;
t t
X and left pleural spaces.In some patients, however, there is an
X
Figu r e 3 1 - 9 . P r i n c i p leo f lu n g r e tr a ctio no win g to p e u r a effusi on.Thi s
pat r e n tw t h a l a r g ep l e u r a le ffu sio nr s r a d io g r a p h eind ve n tr a lrecumbency.
F lui d ,t h e r e f o r e ,h a s g r avita te dve n tr a lly,r e su ltin gin d o r sa d lspl acement
ung .T h e r eh a s b e e ne x te n sived o r sa d l isp la ce m e notf ve n tr a lul ng,but thi s i s
e ca u seth e flu id co le cte d ve n tr alto the l ung
not a p p a r e n tr a d i o g r a p h r cablly
has n o t b e e n s t r u c kt a n g e n tia lly b y th e x+ a y b e a m .T h e o n ly ung retractl on
t hat i s a p p a r e n its i n t h e r e g io n sin d ica te db y x b e ca u seh e r e flui d betw een
t he l u n ga n dt h o r a c i cw a l is str u ckta n g e n tia llyb y th e x- r a yb e a m .l n the regi on
bet w e e nt h e x ' s , t h o r a cicr a d io p a cityis in cr e a se dth , e h e a r tis o bscured,and
pulm o n a r yv e s s e l si n t he p a r tia llyco lla p se dlu n g a r e visib le( c omparew i th
F ig.3 1 - 5 8 ) .
cause of adjacent, partially collapsed lung, which alters the config-
uration of the fluid.
Blunting of costophrenic sulci
Whether or not the costophrenicsulci become blunted by pleural
fluid dependson the position of the patient during radiographic
examination. In sternal recumbency, fluid gravitates ventrally, and
the costophrenicsulci typically appear normal. In dorsal recum-
bency, fluid gravitatesinto the dorsal portion of the thorax, re-
sulting in blunting of costophrenicsulci.
There are other differencesbetweendorsoventraland ventrodor-
sal radiographswhen free pleural fluid is present.lln dorsoventral
* *
,-j:JJ*,:i-;-,'*i-
I appearance
radiographs, the fluid that has gravitated ventrally silhouetteswith
the heart and the ventral part of the diaphragm. In ventrodorsal
diaphragmbecausethe fluid is distributed over a larger areain the
dorsal thorax, where it does not contact the heart or the dome of
the diaphragm (Fig. 3l-10; seealso Fig. 31-5). Fluid doesnot tend
to obscurethe heart as readily in ventrodorsalradiographsbecause
the fluid is located dorsally, above the heart, and does not silhouette
with it (seeFig. 3l-10).
Atypical distribution of free pleural fluid
An atypical distribution of free pleural fluid most often results
from the fact that different parts of the lung have different compli-
ance. \\rhen a portion of a lung has decreasedcompliance,fluid
presentin the pleural spacetends to accumulatearound it because
it is less expansile(more collapsed)than other parts of the lung.
Thus, atypical fluid distribution may be a clue to an underlying
pulmonary lesion (seeFig. 3l-13). Theseatypicalcollectionsresult
in an intrathoracic radiopacity that is usually irregularly margin-
ated and shapedwhen comparedwith opacitiestypically seenwith
pleural effusion. These collectionsmay be confusedwith thoracic
w a l l o r p u l m o n a r yl e s i o n s .
Freepleural fluid is usuallyequallydistributed betweenthe right
asymmetricalfluid distribution. Causesof unilateral pleural effu-
sion or an effusion more voluminous in one pleurai spaceinclude
of a differencein compliancebetweenlungs,the closingof mediastinal
fenestrationsfrom inflammation or a mass, and an anatomically
complete mediastinum.In extensive,unilateral effusion, it may be
difficult to identify whether the resultant opacity is causedby a
pathologic processin the pleural space,the thoracic wall, or the
lung. Pyothorax is a common causeof unilateral pleural effusion.
Pitfalls in pleural fluid diagnosis
Sometimesan erroneousradiographicdiagnosisof pleural fluid is
made. Thickenedpleura may have an appearanceidentical to pleu-
ra1 fluid (see Fig. 3l-2). A distinction may be made by using a
horizontally directedx-ray beam.
Mineralizedcostalcartilagesare sometimesconfusedwith pleural
effusion.Their position is similar, but the concavesurfaceof costal
cartilagesis directed cranially, whereasthe concavesurfaceof fluid-
filled fissuresis directedcaudally(seeFig. 31-5C).
Thoracic wall deformities,such as those seenin chondrodystro-
phoid breeds,may result in increasedradiopacity at the margin of
the lung field. Without knowledgeof this fact, the opacity may be
incorrectly misinterpretedas retraction of the lung from the tho-
racic wall becauseofpleural fluid (Fig. 3l-ll).
Figure 31-1O, Effect of dorsal versus ventral recumbencyon the radiographic
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

Table 31-3. Gauses of pneumothorax

Trauma
Lung rupture
Chestwall rent
E x t e n s i o no f p n e u m o m e d i a s t i n u m
Ruptureof cavitary lung mass

Simultaneous pleural and peritoneal effusion

Occasionally, simultaneous pleural and peritoneal effusions are
detected.In one study, 32 of 48 dogs with simultaneousperitoneal
and pleural effusion had either neoplastic or cardiovasculardisease.
Simultaneouspleural and peritonial effusion is an indicator of
severedisease with poor prognosis.o

I Pneumothorax
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
opacity adjacentto the thoracicwall on the dog's /eft slde and an area of
radiolucency adjacentto the thoracicwall on the rrghtside.Theseare artifacts
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
regi on;
rotationof the patient resulted in its being located at the peripheryof the
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
l"l,eight slde, the opacitycreatedby the costochondraldeformity is located
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
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
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) .
Significance of pleural fluid
Pleural fluid may result from a primary pleural disorder, such as
pleural neoplasm,but most often it is a sign of diseaseelsewhere. lateral
It is usually impossible to determine the cause of pleural effusion
from radiographs. When pleural fluid is present, structures are
obscured, and extremely large lesions can go unidentified.
Vy'hen pleural fluid is identified, careful scrutiny of the radio-
graph is necessary.Occasionally,subtie radiographic findings such
as a rib lesion or asymmetrical distribution of free fluid are noted,
which can be of great help in the evaluation of the patient. In
patients with a large pleural effusion, the indiscriminate approach
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.
AJI pleural effusions are clinically significant, and it is important
to attempt to reach a definitive diagnosis. In small effusions, there
may be no abnormal clinical signs, whereas large effusions usually
result in dyspnea. It should not be assumed, however, that small
effirsions are less significant than large ones. Thoracocentesiswith
appropriate fluid anaiysis should be done when pleural fluid is
identified.3
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-
thorax becausegas usually does enter the fissures of the iollapsed
lung.
Pneumothorax results in lung collapse becauseof the elasticity
space pressure.As lung
volume decreases,the lung contains less air and Decomesmore
related to the degree of collapse, and the increased opacity may
interfere with evaluation of the lung. The pulmonary collapse is
also responsible for the lack of visible lung markings extending to
the periphery of the thoracic cavity, which is u .ommon ruJio-
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
lung is maximally collapsed but still maintains roughly the shape
of a normal lung becauseof its elasticity.
Separationof the heart from the sternum is commonly seenin
radiographs ofpatients with pneumothorax (seeFig. 3l-12).
The heart appears elevated from the floor of the thorax, but
actually it is displaced into the dependent hemithorax owing to
lack of underlying inflated lung to support the heart in its normal
midline position. As the heart falls into the dependent hemithorax,
it slides dorsally creating the appearanceof elevation when seenon
a lateral radiograph (Fig. 31-1a). Although pneumothorax is the
most common causeof the appearanceof elevationof the cardiac
silhouette on the lateral view, this radiographic sign has also been
Table 314. Radiographic signs of pneumothorax
Retractionof pleuralsurfaceof lung away from pleuralsurface
of thoracicwall; space between lung and thoracicwall is
radiolucent
Lung markingsdo not extend all the way to thoracicwall
Lung has increasedopacity becauseof collapse
Appearanceof dorsal displacementof the heart on the lateral
view
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 .

Figurc 31-13. Ventrodorsal view of a dog with a arge right pneumothorax.
T h e r i g h t l u n g i s p a r tia llyco lla p se da n d th e r e fo r eis o f in cr easedradropaci ty. which a unilateral pleural spaceinjection of air occurred.?
T h e r a d i o l u c e natr e al a te r atol th e r ig h tlu n gis d u e to g a s in the pl euralspace.
T h e h e a r th a ss h i f t e dto th e le ft.T h e r eis a r e g io no f h o m o g e neousli ncreased
y
o p a c i t yi n t h e l e f t c r an iahl e m ith o r ath
x a t d u e to e ith e rlu n gconsol i dati on
or
a f o c a r e g i o no f p l e u r a le ffu sr o nlf . th e o' sp a cityis d u e to p leuraleffusi on,i t appearanceof unilateral pneumothorax in lateral radiographs,
si g n i f i e sa b n o r m allu n g co m p lia n ce in th e a d ja ce n lu
t n g .Alteredl ung compi i - which variesaccordingto whether the affectedside is dependentor
a n c ei s a c o m m o nc a u seo f a svm m e tr ico le u r ael ffu sio n .
X - RAY BEAM
*
Figurc 31-14. Principleof separationof the heart from the sternum in
ia t e r a lr a d i o g r a p hws ith p n e u m o th o r a x.
Wh e n th e p a tie n tis pl acedi n l ateral
re c u m b e n c yt,h e l a ck o f a fu lly in fla te dlu n g in th e d e p e ndenthemi thorax
a l l o w st h e h e a r tt o g r a vita teAs. th e h e a r tfa llsin toth e d e p e n denthemi thorax,
it s l i d e sd o r s a l l yb e c a u seo f th e sh a p eo f th e th o r a cicwa l, thus creati nga
spacebetweenthe heartand the sternum.As x-rayspass throughthis space,
t h e h e a r t a p p e a r ss e p a r a te dfr o m th e ste r n u mo n th e la teralvi ew by the
drstancex.
The PleuralSpace 399
seen with decreasedheart size, as a normal finding in dogs with
extremely deep thoracic cavities, and in patients with hyperin-
flated lungs.
As with pleural effusion,diagnosisof pneumothoraxmay not be
possible from survey radiographs. The likelihood of diagnosing
pneumothorax is increased by using a horizontally directed x-ray
beam and placing the patient in a position such that the x-ray
beam is tangent to the area of air accumulation, such as in lateral
recumbency.Decreasingthe milliampere seconds(mAs) by 50%
enhancesvisualizationof the air in the horizontal-beamradiograph
by rendering the lung more opaque (seeFig. 3l-I2C). Justification
for use of horizontal-beam radiography to detect pneumothorax
should be based on the suspectedunderlying cause.For example,
a pneumothorax resulting from lung diseaseis a potentially serious
event,s'6whereas a small pneumothorax occurring after trauma
with no associatedclinical signs may not be significant.
Some attention has been given to identi$'ing the best radio-
graphic view to use to detect pneumothorax. In one study of
induced pneumothorax, the vertical-beam left lateral recumbent
and the horizontal-beam ventrodorsal views were the most effective
for detection of pneumothorax. The right lateral view was most
sensitive for detection of differences in the amounr of air in the
pleurai space.TIt has also been suggestedthat pneumothorax is
easierto detect in dorsoventral radiographsthan in ventrodorsal
radiographs.8
In most animals, pneumothorax is bilateral, and this relates
either to a bilateral source of pleural air or to movement of air
acrossthe mediastinum.Resultsfrom a study of induced pneumo-
thorax suggestthat air can readily move acrossthe mediastinum
becausebilateral pneumothorax was observedin 22 of 24 dogs in
Unilat-
eral pneumothorax, however, can occur for the same reasonsas
unilateral pleural effusion. There is some controversy regarding the
nondependent.Unilateralpleural spaceair may be more apparentif
the affectedside is nondependentbecausethe air collectsaround
the dorsocaudalportion of the caudal lobe. In this situation, the
air collectionis struck tangentiallyby the x-ray beam. If the affected
side is dependent, the air may appear to collect against the
mediastinum and is struck en faceby the x-ray beam (Fig. 3l-15).
It has also been stated,however,that unilateral pneumothorax is
more apparentwhen the affectedpleural cavity is dependent.T
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.
Pitfalls in pneumothorax diagnosis
Skin folds can result in an extremely radiolucent area superimposed
over the lateral aspect of the thorax on ventrodorsal views. In
many patients, it may not be possible to identifz lung markings in
the radiolucent area. In these instances,the correct diagnosisof
skin-fold artifact is usually made by noting that the opacity of the
fold extendsbeyond the limits of the thorix (Fig. 3t-17).
4 OO NE CKA ND TH OR AX -C OMP AN IO AN
N IM ALS

Fi gure 31-15. R i ght/A / and l eft fB l areralthoracl crad rographs of a

dog w i th a arge l eft and a smal ri ght pneumothoraxA., The l arge
pneumothorax i s nondependent and col l ectsaroundthe eft c audal
obe, resul ti ngl n cear vsual i zati on of col apseof the l obe.Therei s a
smal areaof radi oucencyventralto the heartow l ngto a s l ght s hi fti n
cardi ac posi ti on to the ri ght.N ote the l ackof heartdi spl ac ement be
causeof the al mostful l yi nfl ateddependentri ght ung,w h c h s upports
the hearton or nearthe m dl i ne.Therei s a traumati cl ungbula i n the
ri ght caudall obe. P neumomedi astl num i s al so present.B , The l arge
pneumothorax i s now dependent.R atherthan bei ngl oc atedbetw een
the l ung and the thoraci cw al l , w here i t can be struc k tangenti al l y
by the x-raybeam, ai r s l ayeredagai nstthe depende nts i de of the
medasti num.Therel s i ncreased separati on betw eenthe heartandthe
sternumow ng to atel ectasiof s the dependentl eft l ung,w hl c hpermi ts
the heartto fal nto the deoendentheml thorax. P neumomedl as ti num
i s al sopresent.

F igur e 3 1 - 1 6 . V e n t r od o r savie L w o f th e th o r a xo f a ca t with tensi onpneumothorax. The

nc re a s e dp e u r a s p a c ep r e ssu r eh a s d sp la ce dth e d a p h r a g mcaudaLlto y the extentthat l ts
c os t a a t t a c h m e n t sa p p ea ra s te n t I ke p r o je ctio n frs o m its th o r aci csurface.A ddi ti ona
l y the
hearti s s h i f t e dt o t h e e f t b y th e in cr e a se dr ig h tp le u r asp a cep r e ssure.
 The PleuralSpace 4Ol

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.

8. Aronson E, Reed AL; Radiology corner-pneunothoru: Ventrodorsal or dorsoven-

tral view. Does it make a difference?Vet Radiol Ultrasound 36:109. 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.

2. True or False. Small pleural effusions are typically seen more

clearly in dorsoventral rather than ventrodorsal radiographs.

3, True or False.When a horizontal x,ray beam is used to radio-

graph the thorax of a patient with pleural effusion, a straight fluid
line is typically seen.

4. List at least three roentgen signs of pleural effusion present in

Figure31-1B.

5. Was the dog in Figure 31-18 in dorsal or sternal recumbency

when the radiograph was made?

6. The finding of simultaneouspleural and peritonealeffusion:

A. is usually the result of overzealousfluid administration.
B. has no particular significance.
C. is typically associatedwith a poor prognosis.
D. is usually due to a diaphragmatic hernia.
Figurc 31-17. Ventrodorsal viewof thethoraxof a dogin whicha skinjold
artifact
is visible.
Theseartifacts mayeasilybe confused withpneumothorax.
Theskinfolditselfhastheappearance of a ungmargin, wth ad1acentradiolu- 7. True or False.Visualizationof interlobar fissuresrs more com-
cencythatmaybedueto gasin thepleural space. Nolungmarkings arevisible mon with pleural effusion than with pneumothorax.
in theregionlateralto thelung.Thecorrectassessment of skin-fold is
artifact
madeby noting thatthecaudal extentof the lungmarginextendsbeyond the
limitsof thethoraciccavity.Additionally,
no airis seenbetween the lungand
thediaphragm.

In chondrodystrophoidbreeds,the costochondralregion often

appearsopaque. If the dog's sternum is rotated slightly to one side
for the ventrodorsal or dorsoventral view during radiographic
examination, the area peripheral to the opacity appearsradiolucent,
which can be convincing evidence for pneumothorax. Lung mark-
ings may be difficult to identift in this radiolucent region, and it
may be necessaryto resort to the use of horizontal-beamradiogra-
phy (seeFig. 31-11).

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.

3. Bauer I Woodfield JA: Mediastinal, pleural, and extrapleural diseases.In Ettinger

SJ, Feldman EC (eds): Textbook ofVeterinary Internal Medicine,4th ed. Philadelphia,
WB Saunders,1995.

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.

5. Yoshioka M: Management of spontaneous pneumothoru in 12 dogs. J Am Anim

Hosp Assoc 18:57,1982.

6. Schaer M, Gamble D, Spencer C: Spontaneous pneumothoru associated with Figure 31-18.

 4 O2 NE CKA ND T H O R AX -C OMP AN IOAN
N IN 1 A LS

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!

graphicaliy normal unless there is an obvious alteration in size or
shape;it is also important to considerthe patient'sbreed whenever
the heart is evaluated. If uncertainty about the radiographic ap-
pearanceof the heart remains,the next step should be echocardiog-
raphy rather than spending time anguishing about normality versus
diseasein the radiograph.There are, however,certain radiographic
signs that correlate with specific cardiac lesions, especially when
these are considered in light of clinical history, physical findings,
and other radiographicobservations;thesesigns will be discussed
nere.
As a result of the uncertainties of cardiac radiography, a system
of cardiac measurement was designed to take into account the
inherent breedvariation in cardiacsize.The systemis called"verte-
bral heart scale."' To quantify heart size, the lengths of the long
and short axes of the heart are measuredand scaledagainstthe
length of vertebraedorsal to the heart, beginning with T4. Based
on examinationof 100 clinically normal dogs,the normal vertebral
heart scale is 9.7 + 0.5 vertebrae. Because95o/oof a normal
population resideswithin 2 standard deviationsof the mean, the
normal scalerangesfrom 8.7 to 10.7.This a relativelywide range
and it resultsfrom inherent breed variation in cardiacsize,as was
noted earlier.The vertebralheart scalemay be useful for beginning
interpreters,but it has not been proven superior to subjectiveheart
assessment.
To facilitate recognition of certain cardiac abnormalitiesin the
dorsoventralor ventrodorsalradiograph,the cardiacsilhouettecan
be thought of in terms of a "clock face."Bulgesand bumps on the
cardiac silhouette,causedby dilation of parts of the heart, can be
Iocatedby a clock analogy-that is, in the 1 o'clock to 2 o'clock
position (Fig. 32-2). This system can assistone in remembering
the causesfor some alterationsin shaoeof the cardiacsilhouette.
Left atrium. The left atrium is to the right main stem
bronchus,and medial and ventral to -.dirl
the left main stem bronchus.
The only left atrial abnormality that can be detectedradiographi-
cally is left atrial dilation. In the lateral view, left atrial dilation
causesdorsal deviation of the left main stem bronchus (Fig. 32-3)
and an increasein heisht of the caudodorsalborder of the heart.
Figure 32-2. Diagramof the heart in a ventrodorsa(or dorsoventral) view
I ustratingthe clockfaceanalogy.Locationsof dilationof the left auricle(LAu),
main pulmonaryartery(MPA),aorticarch (AA),and rightatr um 1FAlare shown:
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
1 2 : 3 0 ;R A ,b u g e a t 9 :3 0to 11 :3 0 .
The Heartand GreatVessels 4O3
Also, when the left atrium is dilated, a slight concavity is typically
seen in the approximate location where the left atrium meets the
left ventricle, on the caudal aspect of the cardiac silhouette. In the
ventrodorsal or dorsoventral projection, left atrial dilation causes
the left and right main stem bronchi ro diverge (see Fig. 32-3).
Superimposition of the dilated left atrium on the cardiac apex
occasionallyresults in a summation effect causing a double opacity
(seeFig. 32-3). The dilated left atrium may also causesignificant
compressionof the left main stem bronchus.
Dilation of the left atrial appendage(auricle) is recognizedless
often than dilation of the left atrium. In the ventrodorsal or
dorsoventral projection, dilation of the left auricle produces focal
bulging of the 1eft cardiac border between the main pulmonary
artery and the apex of the heart in the 2 o'clock to 3 o'clock
position (Fig.32-a).
Left ventricle. The left ventricle is relatively thick-walled; there-
fore, hypertrophy causeslittle distortion of its conrour.Also, hyper-
trophy of the left ventricle occurs at the expenseof lumen volume,
rather than causing heart size to increase.Thus, a heart with
considerable left ventricular wall hypertrophy may appear radio-
graphically normal. With severe left ventricuiar hypertrophy, the
heart may elongate,causingdorsaldisplacementof the trachea(Fig.
32-58). This dorsal displacement involves the entire intrathoracic
portion of the trachea, from the thoracic inlet to the carina,
resulting in a decreasein the angle between the trachea and the
thoracic vertebrae (see Fig. 32-5A). Pleural effusion may cause
similar tracheal displacement,at least in cats, even in the absence
of significant cardiomegaly.aTherefore, when the cardiac silhouette
is obscuredby pleural fluid, the tracheovertebralangle is not a
reliable sign of left ventricular elongation. In the ventrodorsal
or dorsoventralprojection, there are no dependablesigns of left
ventricular hypertrophy other than the previously mentioned in-
creasein heart length.With severehypertrophy and increasedheart
iength, the cardiac apex may be displaced into the left hemithorax.
In reality, left ventricular hypertrophy is very difficult to assess
radiographically,and suspectedhypertrophy should be confirmed
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.
Generalized cardiomegaly. There are no specific radiographic
signsof generalizedcardiomegalybecausegeneralizedcardiomegaly
results in an overall increasein heart size without soecific chamber
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 324. Left lateral1Aland ventrodorsal/B/ thoracic radio-

g r a p h so f a do g with e n la r g e m e notf th e le ft a tr iu mand auri cl edue
to mitral insufficiency. Notlcethe bulgingaurlce (soltdarrows)along
v,ew and
t h e l e f t s i d e o f th e ca r d ia csilh o u e ttein th e ve n tr o dorsal
elevationof the left mainstembronchus(openanows) in the lateral
Drorectron.
 The Heartand GreatVessels 4O5

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

Figure 32-6. Lateral (A) and ventrodorsal 1Bl views of a dog

w i t h t r i cu sp idd ysp la siaT.h e r ig h ta tr iu mis se vereydi l atedand has
r e s u l t e din a la r g eb u lg eo n th e cr a n iaa sp e ctof the heart,sl i ghtl y
t o t h e rig h tin th e ve n lr o d o r savie
l w.

megaly is myocardial dysfunction. The vertebral heart scale, de-
scribed earlier,was designedto allow a more accurateassessment
of overallheart size;problemswith this techniquewere mentioned.
Others have suggestedthat the heart should occupy between 2.5
and 3.5 intercostalspaceson the lateral view. This, too, is subjec-
tive, and assessment of the overall size of the cardiac silhouetteis
best accomplishedusing subjectivecriteria developedby repeated
viewing of thoracic radiographswith echocardiographicconfirma-
tion of suspicions.Generalizedcardiomegalymay also result from
poor ventilation,with the thoracic cavity being small as a result of
incomplete aeration of the lung (Fig. 32-10). Making a radio-
graphic diagnosisof mild cardiomegalyis inaccurate;if more accu-
rate information is desired,echocardiography should be performed.
Changes in great vessels
Caudal vena cava. The caudal vena cava is variable in diameter
depending on the stage of the cardiac cycle and the degree of
hydration. It is a very insensitiveindicator of central venous pres-
sure, and firm conclusionsabout hydration or venous pressure
should not be basedon the radiographicappearanceof the caudal
vena cava. A quantitative assessmentof caudal vena cava size,
comparedwith aortic diameter,was undertakenin dogs with right
heart failure. The diameter of the caudal vena cava as measured on
a left lateral thoracic radiograph was comparedwith the diameter
of the descending aorta, the length of the thoracic vertebra above
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:

Figure 32-8. Left lateralthoracicradiographof a dog with marked

roundingof the right ventricle.Not ce that the apex (arrows)oI ihe
h e a r t n o l o n g e rc o n ta ctsth e ve n tr a lfo o r o f th e th o r a x.T hi s radi o-
g r a p h i cs i g n i s s u g g estiveo f h yp e r tr o p h y,
r a th e rth a n d ila tion,of the
ri q h tv e n t r i c l e .

dogs with right-sided heart diseaseand 35 control dogs. The ratio
of the caudal vena cava to each of the three structures was signifi-
cantly larger in dogs with right-sided heart disease.A caudalvena
cava-to-aorta ratio of 1.5 was found to be strongly suggestiveofa
right-sided heart abnormality. There was, however, considerable
overlap in the caudal vena cava-to-aorta ratio between normal
dogs and dogs with right-sided heart disease.Therefore,the ratio
of caudalvena cavaldiameterto aortic diameterhas no clinical use
in most patientswith right-sidedheart disease.'
Aorta. Either the entire aortic arch or only the descendingpart
of the arch may becomedilated.Dilation of the entire arch is most
commonly associatedwith turbulence resulting from valvular or
subvalvularaortic stenosis(Fig.32*11).Dilation ofthe descending
part of the arch is most commonly associated with turbulencefrom
a patent ductus arteriosus (see Fig. 32-5). Dilation of the entire
aortic arch resultsin widening of the caudal portion of the cranial
mediastinum or a bulge on the cranial aspectof the heart on the
lateralview (seeFig. 32-ll). Dilation of tlie descendingportion of
the arch is usually seen only on the dorsoventralor ventrodorsal
view as a widening of the aorta as the lateral aortic margin is
followed cranially from the caudal thoracic area.
In aged cats, the aortic arch may be elongated and thereby
appear somewhat redundant; this is often accompaniedbv an
exaggerated"horizontal" alignment of the heart (inireased sternal
contact), occurring in 2\o/oto 40o/oof cats that are 10 to 15 years
of age and older.6The abnormally shapedaortic arch may appear

K-. $

Fi g u r e 3 2 - 9 . R l g h tla te r a1l 4 )a n d d o r so ve n tr aiBlth

l an11-year-ol dD achshundw i thsevere,apparentl ygeneral i ze dc ardi omegay
o r a cicradi ographsof N otethe
bronchus(small,thin arrows)and the bulge in the left cardlacborderat the 3 o'clock positionlsmal/arrowheads); and the slightlydilatedpulmonaryvelns lopen
ar r o w s ) . T h et r a c h e aa n d b ifu r ca to n( la r g ea r r o wh e a do) f th e caudall obe stem bronchiare di spl acedto the ri ghtof mi dl i nedue to the l eft heartenl arqerre-:.
es p e c i a l lbyy t h e l e f t atr ia e
l n la r g e m e nwh
t, ich is a lsoca u sin gthe l eft caudall obe-stembronchusto be l essvi si bl ei n the dorsoventral vi ew .
4O8 NE CKA ND T H O R AX -C OMP AN IO AN
N IM A LS
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
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
. g r e eo f ve n tila tio m
e n la r g e dDe
to be tortuous on the lateral view, or it may appearas a lung mass
on the ventrodorsalor dorsoventralview (Fig. 32-12)' The exact
causefor these changesof aging has not been conclusivelydocu-
mented."
Main pulmonary artery. Dilation of the main pulmonary ar-
tery appearsin the ventrodorsal or dorsoventralview as a bulge
on the left cranial part of the cardiacsilhouettein the 1 o'clock to
2 o'clock position (Fig. 32-13; seealso Figs.32-2, 32-5' and 32-7 ).
Main pulmonary afiery dilation is typically not seenin the lateral
view. In cats,dilation of the main pulmonary artery is usually not
seen on either view becauseof the more medial position of the
artery, which leads the enlargedartery to be superimposedover
the cardiac silhouette. Dilation of the main pulmonary artery
results from increasedturbulence (pulmonic stenosis),increased
pressure(heartworm disease),or a combination of both (patent
ductus arteriosus).
Heart failure
Left-sided heart failure. Left-sided heart failure is most com-
monly associatedwith incompetenceof the mitral valve (Fig. 32-
14) and with mvocardialdisorders.With establishedieft-sidedheart
failure, the left atrium is usually dilated and pulmonary veins are
usually larger than their correspondingarteries.Venous enlarge-
ment without pulmonary edema is not a sign of heart failure
(Fig. 32-15). Venous enlargementis a sign of pulmonary venous
hypertension, and this hypertension may not have reached the
point of fluid transudation into the lung. Compressionof the left
main stem bronchus by an enlarged left atrium may be sufficient
to elicit a cough. In left-sided heart failure, the left ventricle may
be elongated,causingdorsal displacementof the baseof the heart.
With sudden left-sided heart failure, the left atrium and pulmonary
veins may not have had time to dilate and can appear normal;
thus, pulmonary edema may develop before veins have had suffi-
cient time to dilate.
Pulmonary edema is a natural consequenceof left-sided heart
failure. Pulmonary edema begins as transudation of fluid from the
capillaries into the interstitium as venous hydrostatic pressure ex-
:lrlllll::llyl9
iiiuut:iiiiiutrl
rr rl;q]|r,,iiiigil!
/A / and exhaati on /B /. N ote the dramati cdi fferencei n ap pearancof
e the
n ust be takeni nto consl derati on
w hen heartsi zei s bei ngeval uated.
ceedstissue oncotic presslrre.Interstitial edema results in overall
increasedunstructured opacity of the lung and blurring of vessel
margins; this is difficult to identifii radiographicallybecausethese
findings also occur with underexposedradiographs,with radio-
graphs made on exhalation, and in aged lungs with increased
interstitial connectivetissue.Progressivepulmonary edema results
in fluid spilling into the alveoli and the developmentof air bron-
chograms(seeChapter 34). Cardiogenicpulmonary edemamay be
patchy in distribution, especiallyin cats (Fig. 32-16). Cardiogenic
pulmonary edema typically resultsin coughing in dogs but not in
cats.In dogs with left-sidedheart failure secondaryto cardiomyop-
athy, lung edema is often concentratedin the peribronchial and
interstitial compartments (Frg. 32*17). This radiographic appear-
ance is actually more typical of inflammatory lung diseasethan of
cardiogenicedema, but the typical coexistingclinical and radio-
graphic signs (cough fin dogs], dyspnea,fatigue, heart murmur,
and cardiomegaly) usually point the clinician to the diagnosis of
peribronchial and interstitial edema rather than inflammatory lung
disease.Echocardiographyis necessaryfor a definitive diagnosisof
myocardial dysfunction.
Right-sided heart failure. Except for right-sided heart failure
resultingfrom heartworm disease,pulmonic stenosis,and tricuspid
dysplasia, the right ventricle rarely fails without pre-existing left
ventricular failure. The appearanceof the heart in patients with
right-sided heart failure depends on the inciting cause of the
failure. Physiologically,right-sided heart failure results in increased
central venous pressure, which may cause the vena cava to be
dilated. However, as mentioned previously, caudal vena cava en-
largement is an insensitive radiographic sign of elevated central
venouspressure.
Increasedcentralvenous pressureresultsin chronic passivecon-
gestion of the liver with hepatomegalyand ascites.Pleural effusion
may also develop secondaryto the elevatedcentral venous pressure
(which obscures the heart and diaphragm owing to silhouette
sign) (Fig. 32-18). Pleural effusion resulting from right-sided heart
failure is more common in the cat than in the dog. In the dog,
right-sided heart failure resulting in pleural effusion usually stems
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 .

Congenital cardiovascular lesions Radiographicsigns of patent ductus arteriosusinclude the fol-

Becausemost cardiac patients examined and treated in small ani-
mal practice have acquired cardiac disease,the emphasis given to
congenitallesionsin this chapteris limited.
Patent ductus arteriosus
The ductus arteriosus connectsthe aorta with the pulmonary artery
and servesas an in utero bypassfor pulmonaryaiterialblood flow
into the systemic circulation. Typically, the ductus arteriosus closes
shortly after birth. If the ductus fails to close, the patent ductus
allows blood to shunt from the aorta into the pulmonary artery.
As systolic and diastolic pressures in the aorta are higher than
systolic and diastolic pressures in the pulmonary artery, blood
flows continuously through the ductus. Pressureand flow in the
pulmonary circulation are therefore increased.Commonly affected
breeds are the Bichon fris6, Chihuahua, Cocker spaniel, English
Springer spaniel, German shepherd, Keeshond, Labrador retriever,
Maltese,Pomeranian,Poodle,Shetlandsheepdog,Welsh corgi, and
Yorkshire terrier.T
lowing (seeFig. 32-5):
1. Segmentalenlargementof the proximal descendingaorta (due
to turbulent flow)
2. Enlargementof the main pulmonary artery (due to increased
pressureand flow)
3. Enlargementof the left atrium, and possiblythe left auricle
(causedby increasedflow)
4. Enlarged Ieft ventricle (causedinitially by dilatation)
5. Enlargedpulmonary arteriesand veins (causedby increased
flow and pressure)
It is important to remember that not all of these radiographic
signs may be visible in any one patient.
Pulmonic stenosis
Malformation of the pulmonic valve is the most common causeof
pulmonic stenosis,but narrowing of the right ventricular outflow
tract below the valve or narrowing of the supravahrrlar area mav
4 IO NE CKA ND TH OR AX -C OMP AN IOAN
N IN /IA LS

'. : 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 32-13. Left lateraliA) and dorsoventral/B/ thoracicradlographs of a dog

w i t h h e a r t w o r md i se a seT. h e r eis r ig h tve n tr icu Leanr la r g e ment i n bothprol ecti ons
The main pulmonary arlery (wide arrowhead)is distended in the dorsoventral
proiection,and the left and right caudallobarpulmonaryarteries(arrowheads) are
d i l a t e da n d t o r t u o u sr n b o th p r o je ctio n s. l barpul monaryarteryrs
T h e r ig h tcr a n ialo
a l s oe n l a r g e 0 .
 The Heartand GreatVessels 4ll

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 32-17. Close-upview of the lung caudalto the heart in a

D obermanw i th di l atedcardi omyopathy and i eft heartfai l ure.P ul mo-
nary edema in large dogs with dilated cardiomyopathycommonly
assumesthi s ml xedi ntersti ti al /bronchi pattern,
al w hi ch i s more c on-
si stentw i th i nfl ammatory l ung di seasethan w i th pul m onaryedema.
Thi s patternl i kel yresul tsfrom perl bronchi edema,
al whi c h has not
yet progressed to al veol aredema.The si gnal mentand otherc l i ni c al
and i magi ngfi ndi ngsof heartdi seaseshoul dal l ow th e di s ti nc ti on
betw eenedemaand i nfl ammatory l ungdi seaseto be made.

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
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
region resultsin elevatedright ventricular pressureand turbulent
blood flow distal to the narrowing.
Commonly affected breeds are Basset hound, Beagle, Boxer,
Boykin spaniel, Chihuahua, Chow Chow, Cocker spaniel, Labrador
retriever,Newfoundland, Samoyed,Schnauzer,West Highland
White terrier, and other terrier breeds.T
Radiographic signs of pulmonic stenosisare these (see Fig.
32-7):
1. Dilated main pulmonary artery (causedby turbulence)
2. Enlargement of the right ventricle (causedby hypertrophy)
3. Normal pulmonary vessels(if right-sided heart failure devel-
ops, vesselsmay be small owing to undercirculation and reduced
cardiacoutput)
Aortic stenosis
Narrowing of the subvalvular region of the left ventricle is more
common than primary valvular stenosis.As in pulmonic stenosis,
the narrowing results in increased resistance to left ventricular
ejection. Increasedleft ventricular pressure and turbulent flow
develop in the aortic arch distal to the obstruction. Mitral valve
dysfunction and regurgitation may occur secondary to the mitral
annulus becoming misshapen.
Commonly affected breeds are Boxer, Bull terrier, German shep-
herd, German shorthaired pointer, Golden retriever, Great Dane,
Newfoundland, Rottweiler, and Samoyed.T
Radiographicsigns of aortic stenosisinclude (seeFig. 32-77):
l Enlargement of the aortic arch (due to turbulent flow)
2. Elongation of the left ventricle (due to hypertrophy)
3. Left atrial dilation if secondary mitral dysfunction develops
4. Normal pulmonary vesselsunless secondary mitral dysfunc-
tion develops,then pulmonary veins may become enlarged
The Heartand GreatVessels 413
eadi ngto ri ght heartfai l ure.(C ourtesyof A ni mal Medi c alC l i ni cof B othel l ,
Ventricular septal defect
Abnormal development of the heart results in a communication
between the left and right ventricles. Most of the time, the commu-
nication is located dorsally in the septum, just ventral to the aortic
valve. Becausesystolic pressureis higher in the left ventricle, blood
flows into the right ventricle during systole. Little flow is present
during diastole becauseof the similar diastolic pressurein the two
ventricles.Owing to the upper location of the defect,most shunted
blood immediately enters the pulmonary artery and not the right
ventricle. The volume of blood shunted with each contraction
dependson the size of the defect,but the magnitude of shunting
is typically less than with patent ductus arteriosus.
Commonly affected breeds are the English bulldog and the
English Springer spaniel.7
The magnitude of the radiographic signs seen with ventricular
septal defect dependson the amount of blood shunting through
the defect (Fig. 32-19).
1. Mild right ventricular enlargement may be present when
shunting is large (due to increased pressure and flow during sys-
tole).
2. Normal to slight increase in pulmonary artery and vein size
may occur (due to mild to moderate increasedpulmonary blood
flow; enlargement is typically less than with patent ductus arterio-
sus).
Tetralogy of Fallot
Tetralogy of Fallot consists of pulmonic stenosis,right ventricular
hypertrophy, ventricular septal defect, and overriding aorta (Fig.
32-20). Thus, during systole, the increased resistanceto flow out
of the right ventricle causesunoxygenatedblood to flow acrossthe
ventricular septal defect into the 1eftventricular outflow tract. The
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,,.
circuiation from the right ventricle. Thus, systemicarterial blood is
poorly oxygenatedand cyanosisis a ciinical feature ofthis anomaly.
Commonly affected breeds are the English bulldog and the
Keeshond.t
Radiographic signs of tetralogy of Fallot include:
l. Right ventricular enlargement (due to hypertrophy)
2. A more angular appearanceof the cardiacsilhouettebecause
ofshifting ofthe apexto the right in responseto the right ventricu-
lar hypertrophy
3. Small pulmonary arteries and veins (due to pulmonic stenosis
and ventricular septal defect; blood flows from the right ventricle
into the aorta rather than into the lungs)
Tricuspid dysplasia
Commonly affectedbreeds are German shepherd,Golden retriever,
Great Dane, Labrador retriever, and Weimaraner.T
Radiographic signs of tricuspid dysplasia include the following
(seeFig. 32-6):
1. Right atrial enlargement
2. Small pulmonary vesselsif the insufficient valve results in
decreasedcardiac output
Situs inversus
Situs inversus is an extremely rare congenital malformation in
which the thoracic and abdominal viscera are reversed,and appear
,lrnllll
l'lliri:1rl
Figure 32-19. Right lateral /A/ and dorsoventral/8/ thoracic
radi ographsof a dog w i th a ventri cul ar septaldefect.Th e pul mo-
nary arteri esand vei ns are sl i ghtl yl argerthan norma lbut the
appearance of the cardi acsi l houettei s unremarkabl e. T he apex
di spl acementto the l eft i n B i s due to the fact thatthe radi ograph
w as madew i th the dog i n sternaL recumbency, C V entri c ul ogram.
C ontrastmedl um w as i nj ectedi nto the l eft ventri cl e there
; is
si mul taneous opaci fi cati on of the ri ght ventri cl eand the mai n
pul monaryarteryby contrastmedi umshunti ngacrossa s eptal
defect /smal /arrow ). A orti cval vul ardyspl asi ai s al so pres ent
(curvedarrow).
as mirror imagesof their normal location. It is usually associated
with sinusitis and bronchitis, in which instance the condition is
known as Kartagener'ssyndrome.',n Radiographically (Fig. 32-21),
the cardiac apex is on the right, the caudal vena cava is on the left,
the pylorus and fundus of the stomach are reversed, the right
kidney is more caudal than the left, the liver lobes are reversed,
and so forth. Other than the associatedrespiratoryproblems, this
conditionhas little clinicalsignificance.
Acquired cardiovascular lesions
Mitral insufficiency
Chronic mitral valve insufficiency is the most common heart dis-
easein dogs.roIt results from primary degeneration of the mitral
valve leaflets, with possible dysfunction or malformation of the
chordae tendineae or papillary muscles. Valve dysfunction results
in incomplete left ventricular emptying on systole, and reflux of
blood into the left atrium during systole. Left atrial pressure and
blood volume are elevated. Radiographic signs of mitral insuffi-
ciency are the following (seeFigs.32-3 and 32-4):
1. Left atrial enlargement (due to regurgitant flow)
2. Possible left ventricular dilatation. (Actually, echocardio-
graphic evidence of Ieft ventricular dilatation is common, but in
radiographs this alteration may not be detectable.)

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-
tension)
4. Pulmonary edema (due to left heart failure)
Heartworm disease. Heartworm diseaseis probably the most
common cause of acquired cor pulmonale in dogs. The adult
parasitesusually reside in the right ventricle or in the pulmonary
arteries,occupying spacein the lumina, causingphysicalobstruc-
tion of the outflow tract, and destroying normal laminar blood
flow in the pulmonary arteries.Typically,as the diseaseprogresses,
Figure 32-21. Ventrodorsalthoracc radiographof a dog with Kartagener's
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.
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
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
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
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 .
The H eartand GreatVessels 415
the vascularintima becomesroughened,irregular, and hypertro-
phic, further compromising laminar flow. The pulmonary irteries
dilate and become tortuous. Perivascularfibroiis followi oulmo-
nary hypertension,and the diseasebecomesself-perpetuaiingto
the extent that progressivecardiovascular changesmay occur even
after the parasitesare no longer present.
Typical radiographicsigns of heartworm diseaseare the follow-
ing (seeFig. 32-13):
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
Hypertrophic cardiomyopathy is characterized by a hypertro-
_
phied, nondilatedleft ventricle and absenceof other cardiacdisease
or systemicor metabolic abnormalities capableof producing hyper-
trophy.l'?Hypertrophic cardiomyopathy occurs in dogs, but is more
common in the cat, in which the following radiographic signs are
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).

Figure 32-23. Left lateral/A/and dorsoventral1Blthoracicradiographs

o f a d o g w i t h dila to r yca r d io m yo p a thTy. h e r eis g e n e r a li zed
cardi omegal y
I n B , t h e c a u da lo b e a r te r le sa n d ve in sa r e slig h tlye n larged,probabl ya
e f lu idr e te n tto n
c o n s e q u e n cof ( h yp e r vo le m ia ) .
 The Heartand GreatVessels 417

Figure 32-24. Right lateral/A/ and dorsoventral/B/ thoracicradiographsof a cat with

compensated h yp e r tr o p h ic
ca r d io m yo p a thTy.h e r eis littl eenl argement
of the ventri ces,
but there is an appearanceof biatrialen argement(arrows,B) in the dorsoventralprojec-
t i o n . S e v e r e l e fta tr ia
e n la r g e m e n ttyp ica lya cco u n tsforw hatappearsas"bi atri al "enl arge-
m e n t a s t h e e xtr e m e y d ila te dle ft a tr iu m e xte n d sb e yondthe ri ght crani almargi nof
the heart.

l. Extremeleft atrial enlargement,resultingin the characteristic
"valentine" heart shape.The left atrium becomesso large that it
extendsto the right beyond the margin of the right atrium. Often
this appearanceis misinterpretedas biatrial enlargement.
2. Enlargedpulmonaryveins
3. Pulmonary edema
4. Pleural effusion as a late development
Pericardial effusion. As has been described earlier, the epicar-
dial edgesof the heart are normally not visualizedbecauseof the
presenceof a small amount of free fluid in the pericardialsac.This
fluid, between the pericardial sac and the epicardium, silhouettes
the inside of the pericardiai sac and the outside of the heart.
Distention of the pericardialsacwith large amounts of fluid causes
the cardiac silhouette to be enlarged anJ globoid lPig. 32-25). ln
the ventrodorsalor dorsoventralprojection,the edgeofthe pericar-
dial sac may touch the costalmargins bilaterally.Furthermore,the
edge of the distended pericardial sac is often distinct becauseit
undergoeslittle, if any, motion during systoleand diastole.If 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

Figure 32-26. Lateral(A)and dorsoventral/8/ thoracicradiographs of a dog

T h.e h eart i s markedl ysmaLl er
d u e to h vp o a d r e n o co r ticism
w i t h m i c r o c a r d ia
than expected relativeto the size of the thoracic cavity.Acute hypovolemia
sig n s. iCo u r te syo f th e S antaC ruz V eteri nary
p r o d u c e ss i mila rr a d io g r a p h ic
H o s o i t a lS. a n taCr u z.CA.)

Figure 32-27. Left lateraland ventrodorsalthoracicradiographs of a 9-year-oldneut-

ered m a l eG o l d e nr e t r i e vedr o g with p r o g r e ssive
le th a r g ya n d e xerci sei ntol erance.

dial fluid, radiographic signs of congestiveheart failure may also
be present. The causesof hydropericardium may be neoplastic,
inflammatory,congenital,hemorrhagic,or idiopathic.raAmong the
possibie neoplastic causesfor hydropericardium are heart base
tumors (chemodectomas)and metastaticor primary hemangiosar-
comas. Not all neoplasms at the base of the heart invoive the
pericardial sac. Pericardiocentesisand pneumopericardiography
have been recommendedfor the purpose of differential diagnosis
of pericardial diseases.Diagnostic ultrasonographyis now the
method of choicefor imaging such lesions.
Microcardia. The decreasein size of the cardiac silhouette may
be absolute or relative. If relative, the thorax has been overinflated
by one of severalpossibieconditions such as emphysemaor simple
hyperventilation. If absolute, the causesinclude hypovolemia (due
to blood 1oss,shock, or severedehydration),atrophic myopathies,
and hypoadrenocorticism(due to Addison's disease).The patho-
genesisof hypovolemia in Addison's diseaseis apparently equivocal.
Microcardia causedby hypoadrenocorticismhas been induced ex-
perimentally in dogs.'sHypovolemia appearsto be the major rea-
son for the decreasedsize of the heart in the more acute form of
the disease.In the ihronically afflicted patient, however, decreased
cardiac size appears to be caused, at least in part, by electrolyte
imbalance, which theoretically results in decreasedmyocardial mass
resulting from chronicallyweak contractions(disuseatrophy). The
radiographic sign associatedwith microcardia (Fig. 32-26) is, as
the term suggests, the appearanceof a smallerthan normal cardiac
silhouette relative to the size of the thoracic cavitv. No obiective
measurementscan be made for assistance in borderline or eouivo-
cal situations.
References
l. Carlisle CH, Thrall DE: A comparison of normal feline thoracic radiographs made
in dorsal versus ventral recumbency. Vet Radiol 23:3, 1982.
2. Ruehl \{W, Thrall DE: The effect of dorsal versus ventral recumbency on the
radiographicappearanceofthe canine thorax. Vet Radiol 22:10, 1981.
3. Buchanan ]W, Bucheler J: Vertebral scale system to measure canine heart size in
radiographs.J Am Vet Med Assoc 206:194,1995.
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.
5. Lehmkuhl LB, Bonagura lD, Biller DS, Hartman WM: Radiographic evaluation of
caudal vena cava size in dogs. Vet Radiol Ultrasound 38:94,1997.
6. Moon ML, Keene BW, Lessard P, et al: Age related changes in the feline cardiac
silhouette.Vet Radiol Ultrasound 34:5, 1993.
7. Sisson DD, Thomas WP, Bonagura jD: Congenital heart disease.ln Ettinger Sj,
Feldman ED (eds): Textbook of Veterinary Internal Medicine, 5th ed. Philadelphia,
WB Saunders,2000.
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-
9. Stowater lL; Kartagener's syndrome in a dog. I Am Vet Radiol Soc 171174,1976.
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.
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.
12. Fox PR: Feline cardiomyopathies. In Ettinger SJ, Feldman ED (eds): Textbook of
Veterinary Internal Medicine, 5th ed. Philadelphia, WB Saunders,2000.
13. Sisson DD, Thomas WR Keene BW: Primary myocardial disease in the dog. In
Ettinger SJ, Feldman ED (eds): Textbook of Veterinary Internal Medicine, 5th ed.
Philadelphia, WB Saunders, 2000
14. Miller MW Sisson DD: Pericardial disorders. In Ettinger SJ, Feldman ED (eds):
Textbook of Veterinary Internal Medicine, 5th ed. Philadelphia, WB Saunders,2000.
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.
The Heartand GreatVessels 419
ffi Ouestions
l. Why is it not possibleto accuratelyassesscardiovasculardisease
by physically measuring structures seen on thoracic radiographs?
2, \A4rich of the following are generally acceptedas reliable radio-
graphic signs of left atrial enlargement?
A. Dorsal deviation of the Ieft main stem bronchus in the
lateral projection
B. Ventral displacement of the caudal vena cava in the lateral
projection
C. Divergence of the left and right main stem bronchi in the
dorsoventralor ventrodorsalproiection
D. Widening of the arch of the aorta in either projection
E. Medial displacement of the right main stem bronchus in
the ventrodorsal or dorsoventral projection
3. Under which circumstancesis a decreasein the angle between
the vertebral column and the trachea (in the lateral iadiograph)
an unreliable radiographic sign of left ventricular enlargement?
4. True or False.Enlargedpulmonaryveins are a sign ofheart fail-
ure.
5. Which of the following radiographicsigns is generallyassoci-
ated with left-sided heart failure?
A. Increasedcardiosternalcontact in the lateral proiection
B. Elevation of the left main stem bronchus in the lateral
projection
C. Hepatomegaly
D. Ascites
E. Alveolar pulmonary infiltrate
F. Elevationof the axis of the tracheain the lateral proiection
G. Free pleural fluid
6. \{4rich of the following radiographicsigns is generallyassoci-
ated with right-sidedheart failure?
A. Increasedcardiosternalcontact in the lateral Droiection
B. Elevation of the left main stem bronchus in the lateral
projection
C. Hepatomegaly
D. Ascites
E. Alveolar pulmonary infiltrate in the hilar and intermediate
zonesof the lung fields
F. Elevationof the axis of the tracheain the lateral proiection
G. Free pleural fluid
7. List the survey radiographic signs generally associatedwith
patent ductus arteriosus;with aortic stenosislwith pulmonic steno-
sis.
8. List the survey radiographic signs generally associatedwith
heartworm disease;with mitral insufficiency.
9. Provide an accurate radiographic interpretation for Figure 32-
27,left iateral and ventrodorsalthoracic radiographsof a 9-year-
old neutered male Golden retriever dog with progressivelethargy
and exerciseintolerance. List the major radiographic signs.
10. Tiue or False.The heart often appears faisely enlarged in the
dorsoventral view becausethe diaphragm is displaced cranially and
the cardiac apex is displaced into the left hemithorax.
Answers begin on page727,
 CHA P T E R
33
The Pulmonary Vasculature
. TohnM. Losonsky
Diseasesof the cardiovascular and pulmonary systemsmay result
in similar clinical signs.' Thoracic radiographs may assistin differ-
entiating pulmonary from cardiac diseases.An important comPo-
nent in evaluating both cardiovascular and pulmonary diseaseis
assessmentof the pulmonary vasculature. It is important that an
attempt be made to differentiate pulmonary arteries from veins as
this will provide important information pertaining to circulatory
dlmamics.
I Anatomy of the pulmonary
I vasculature
The pulmonary trunk arisesfrom the pulmonary fibrous ring at
the conus arteriosus.2 After coursing 3 or 4 cm, the trunk divides
into left and right pulmonary arteries. The left pulmonary artery
is dorsal to the trachea and divides into two or more branches.
One of two smaller branchesentersthe cranial portion of the left
cranial lobe (craniallobar artery of the left cranial lobe). The larger
branch subdivides and enters the caudal portion of the left cranial
lobe (caudallobar artery ofthe left cranial lobe) and the left caudal
lobe (left caudal lobar artery) (Fig. 33-l).
The right pulmonary artery leavesthe pulmonary trunk at al-
most a right angle and coursesto the right, ventral to the trachea.
The first branch is the right cranial lobar artery. The vesselthen
divides into the right middle lobar, accessory lobar, and right
caudallobar arteries(seeFig. 33-1).
Commonly, one main vein courses from each lung lobe, but
there can be two from the right cranial lobe.'zThe right middle
lobar and right cranial lobar veins merge, as do the right caudal
lobar and accessorylobar veins, before entering the left atrium. All
lobar pulmonary veins from the left lung enter individually into
the left atrium.
42|,
I Radiographicanatomy of the
I pulmonary vasculature
If radiographs are of high diagnostic quality, the pulmonary vascu-
lature of the central (hilar) and middle thirds of the lung can be
seen and evaluated. In larger dogs, pulmonary vasculature may be
seen in the peripheral one third of the lung.
When an artery, bronchus, and vein supplying a lobe are seen
on a lateral radiograph, the artery is dorsal to the bronchus and
the vein is ventrai.'?The right cranial lobar artery, bronchus, and
vein are routinely visible and can serve as reference vesselsfor
evaluation of the pulmonary circulation (Fig. 33-2). The right
cranial lobar artery is more clearly visualized when the animal is
radiographed in left lateral recumbency (Fig. 33-3). When the
animal is in left lateral recumbency,the right cranial lobe is better
inflated, resulting in better visibility of the artery. The right cranial
lobar vesselsare also located ventral to the opacity produced by
the craniodorsal mediastinum, whereasthe left cranial lobar vessels
are superimposed on the mediastinum. Also, in right lateral radio-
graphs, the left and right side cranial lobe arteries and veins are
typically superimposed, making their assessmentdifficult. Thus,
evaluation of the cranial lobe vesselsis best accomolished from a
left lateral view. The paired artery and vein to remaining lobes are
not usually seenon lateral views.
When a lobar artery, vein, and bronchus are seenon a dorsoven-
tral radiograph, the artery is lateral to the vein with the bronchus
located between the two vessels.2 The caudal lobe arteries and veins
are more clearly seenon a dorsoventral view than on a ventrodorsal
view (Fig. 33-4).3Pairedarteriesand veins are seenlessfrequently
in the remaining lung lobes, although cranial lobe vessels are
occasionallyseen.
Pulmonary arteries and veins in the caudal lobe are more clearly
seen in the dorsoventral view because the caudal lung lobes are
Figure 33-1. Lateralpulmonaryangiogramof a 2-year-oldmale,
mi xed-breed cani ne.The di stri buti on
of oul monarvart eri esi s nor-
mal. Note the relativepositionsof the right and left craniallobe
vessels.Note also the right main pulmonary arterypassingventral
to the trachea,and thus locatedventralto the left main pulmonary
artery.
 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
both pulmonary arteries and pulmonary veins
Left-to-rightshunts
Patentductus arteriosus
Ventricularseotal defect
Perip her alar t er iov enousf is t ula
latro ge nicf luid ov er load
Cardiomyopathy(volume overload)
Mitral insufficiencvand heartworm disease
more fully aerated(lesslung silhouettingwith the vessels),and the
oncoming x-ray beam strikes the vesselsin a more perpendicular
manner (lessdistortion).
Although the lobar bronchus lies between the artery and vein, it
is important to realizethat the entire spacebetweenthe artery and
vein is not taken up by the bronchus. The exact position of the
bronchus can be determinedonly if the wall is mineralized.
I Radiographicsigns of the
I pulmonary vasculature
The pulmonary vesselsare dynamic, their size being mainly a
function of intraluminal pressureand volume. Pressureand volume
can change quickly, such as in dehydration from diuretic overuse
or in overhydration from overzealousfluid administration; there-
fore, the appearanceof pulmonary vesselsin a given radiograph
must be interpreted with the knowledge that they may be influ-
enced by medication or administeredtherapies.Sequentialradio-
graphs provide more meaningful information on underlying circu-
latory dynamics, especiallyif therapeutic interventions are changed.
Geometric changes
Sr2e. On the left lateral recumbent radiograph, the right cranial
lobar artery and vein should be approximately equal in size. The
relative size of these two vesselsshould be compared, and the size
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
and veins should be compared with each other and with the
diameter of the 9th rib at the point of intersectionof the 9th rib
and correspondingvessel.The artery and vein of each caudallobe
should be similar in size. The diameter of the artery and vein
caudal to the 9th rib should not exceedthe diameter of that rib.
Table 33-l provides a list of some common diseasesin which
there can be an increasein sizeof both the pulmonary arteriesand
veins.a History, physical examination, electrocardiography, survey
thoracic radiographs, angiocardiographS echocardiography,and
clinical pathology resultscan be used to differentiatethese condi-
tions. The radiographicchangesdepend on the severityand dura-
tion of the disease(Fig. 33-5).
Pulmonary arterial enlargement without venous enlargement
may occur with the diseaseslisted in Table 33-2. Heartworm
diseasein the dog is the most common causeof pulmonary arterial
enlargement.In heartworm disease,vesselenlargementoccurs be-
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
pulmonary arteries
Tunica intimal proliferation or tunica media hypertrophy
Dirofilariasis
An gio stro ng ylia s is
Aelu rostron gylus( f eline)
Thromboembolic disease or primary thromboses
Dirofilariasis
Dissemin ate dintr av as c ular
c oagulat ion
Trauma
Secondaryto cardiacdiseases
An gio stro ng ylia s is
Ren ald ise ase-a m y loidos isglom
, er ulonephr it is
Septicemia
Pancreatitis
Hyperadrenocorticism
Severe chronic lung disease
embolic disease,or both. Thoracic radiographicabnormalitiesseen
in spontaneousdirofilariasisare well documented.s-8 The percent-
age of dogs with right-sided heart enlargement,main pulmonary
artery enlargement, and right cranial lobar pulmonary artery en-
largementhas been reported.TThe percentageof right cranial lobar
pulmonary artery enlargementwas only 47o/o(Fig. 33-6). In that
study, caudal lobar pulmonary arteries were not measuredbecause
the animals were radiographed in dorsal as opposed to sternal
recumbency. In the author's experience, the lobar arteries that
enlargemost frequently in spontaneousheartworm diseaseare the
caudal lobar arteries,with a predilection for enlargementof the
right more than the left (Fig. 33-7). Experrmentally, the right
caudal lobar artery was the first to enlarge and did so most
frequently. The left caudal lobar artery was the next most frequently
enlargedvessel.6'8 It is common in canineheartworm diseaseto see
main pulmonary artery enlargement in associationwith peripheral
pulmonary arterial enlargement(Fig. 33-7).?
In feline heartworm disease,it is unusualto seemain pulmonary
artery enlargementon survey radiographs.'With angiography,
howeveg it is possibleto see that the main pulmonary artery is
enlarged in most cats with heartworm disease;the main pulmonary
artery is positioned such that it is not visible in survey radio-
graphs.tuParenchymalpulmonary arteries are also enlarged and
become tortuous in feline heartworm disease(Fig. 33-B). It has
been reported that enlargementof the central and peripheralpor-
tions of caudal lobar arterieson the ventrodorsalview with nor-
mal-sized caudal pulmonary veins, representsthe earliest radio-
graphic change seen in spontaneousfeline heartworm disease.If
.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 diameter of the caudal lobar artery at the seventh intercostal
spacewas 5 mm or larger, or 4 mm or larger at the ninth intercostal
space,as seenon the ventrodorsalview, this was consideredconsis-
tent with feline heartworm disease.eIn experimental infection of
cats with third-stage heartworm larvae, most cats had peripheral
caudalpulmonary arterial enlargementby 5 months post infection,
but at 9 months post infection, there was resolution of the periph-
eral pulmonary arterial enlargementin more than 50oloof cats.ll
Another important aspect of that study was persistent bronchial-
interstitial lung opacification,appearing similar to feline allergic
lung disease,after vascular changeshad resolved.tlThus, heart-
worm diseaseshould be consideredin cats with radiographicevi
denceof bronchial-interstitiallung opacification,even though car-
diovascularevidenceof heartworm diseaseis not oresent.rr
Other changesassociatedwith canine heartworm diseasethat
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
on the lateral view (Fig. 33-10;.s'oThe foci ofincreasedopacity in
the caudallobeswere present6 months after experimentalinfection
with L. larvae and were still evident 12 months after treatment
(Fig. 33-11). Theselesionsrepresentperipheralpulmonary arteries
with dilation and tortuosity.uFibrous connectivetissueand chronic
inflammatory cellsmay also persistin the arterial wall and perivas-
cular tissue.
Heartworm diseaseis also the most common causeof thrombo-
embolic diseasein that there is arterial occlusionby worm emboli,
or clots.sPulmonary thromboembolism typically resultsin an in-
crease in lung opacity, which has mixed interstitial and alveolar
characteristics. In later stages,or when there is an associated
allergic
responseto the worms, the alveolar component predominates.
Pulmonary infarction in heartworm diseaseis rare.'t
Pulmonary thrombosisor thromboembolismdue to causesother
than dirofilariasismay be associatedwith normal to reducedlung
volume with lobar hyperlucency,and possibly reduced size of
peripherallung vesselsin affectedareas.Radiographicchangesmay
also inciude alveolardisease,hyperlucencyof a lung lobe or lung
region (hypovascular),and pleural effusion, especiallywith in-
farction or cardiac disease.'tIt is important to remember that
many patients with pulmonary thromboembolism do not have
radiographic changeshighly suggestiveof arterial occlusion, and
definitive diagnosis may require nuclear perfusion scintigraphy or
pulmonary angiography.
Table 33-3 outlines the differential diagnosesfor pulmonary vein
enlargement occurring without arterial enlargement (Fig. 33-12)."
Most causesare associatedwith cardiac disease.Pulmonarv vein
i1111''
 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

Fi gure 33-8. D orsoventralvi ew of the thorax of a 3-year-ol dcastratedmal e domes ti c

shorthai redcat. N otethe i ncreasei n the si zeof the caudall obararteri esand abrupttaperngof
the di stalportl onsof the caudall obararteri es.E nl argement of the mai n pul monaryarteryi s
not seen; thi s i s common i n fel i ne heartw ormdi sease.S i x adul t heartw ormsw ere founo
aI necro0sv.

Figure 33-9. Lateralpu monaryarteriogramof a mixed-breeddog

'12m o n t h sa f t e r e x p e r i m e n tainl fe cto nwith th ir d - sta g e h e a r tworm
larv a e .N o t e t h e t o r t u o sityo f th e p u lm o n a r ya r te r ie s,lin e a rfllli ng
def e c t s ( a d u l t
h e a r t w o r ms)n,o n - u n ifo r m l p e r in ga, n d sa c cu-
a r te r lata
I
lar d r l a t r o nos f t h e s m a l le rin tr a lo b aar r te r ie s.Co n tr a stm e d iu mwas
not s e e n m o r e d i s t a l l yin th e ca u d a llo b a ra r te r ie so n su b se q uent
radi o g r a p h iecx a m l n a t i o n s, ln d ica tr ve o f p u m o n a r ya r te r iaol b struc-
t ion. i F r o m B a w i n g s C A, L e wis RE, M cCa l JW: De ve lo p m e nand t
res o l u t i o on f p u l m o n a r ya r te r io g r a p hle
icsio n sin h e a r two r md ise ase.
J A m A n i m H o s pA s s o c16 :1 7 ,1 9 8 0 .)

:.: i:),

Figure 33-1O- Close-uplateralradrographof the dorsocaudallung

field of a 4-year-oldmixed-breed,neuteredfemale dog. Note the in-
creaseddorsocaudal l ung opaci ty.Thi s i ncreasedopac i tyi s due to
caudall obarpul monaryarteri alenl argement, saccul ard i v erti c ul ati ons
of smal larteri es,and associ atedLungdi sease.The dors ov entral v i ew
may be used to confi rmthat thi s opaci tyrepresents ab normalc auda
l obararteri es.
 The PulmonaryVasculature 427

Figure 33-11. Lateralpulmonaryarteriogramof a mixed-breedmale

c a n i n e1 2 m o n t h sa fte rtr e a tm e n o t f h e a r two r md ise a seSlight
. arteri al
e n l a r g e m e nst ,a c c u ladr ila ta tio nosf th e in tr a lo b aarr te r ie s,
a n d mi ni mal
tortuosityremain.{FromRawlingsCA, Lewis RE, McCallJW: Develop-
o f p u lm o n a r ya r te r io g r a p hle
m e n t a n d r e s o l u t i on icsio n sin h eartw orm
d i s e a s eJ. A m A n i m Ho spAsso c16 :17 , 19 8 0 .)

"
I

I iillfu*u l

Figure 33-12. 4, Lateralview of the thorax of an 8-year-oldmale

poodl e.N otethe sl i ghtpul monaryvenousdi stenti o n-theri ghtc rani al
lliiar:.ir1{rrr,.
illr.'r:1Rlr..
iil
l obarvei n i s sl i ghtl yl argerthan the ri ghtcrani all obarartery There
. is
l eft atri alenl argement. D i agnosi s:
mi trali nsuffi ci encand
v dv s func ti on.
B , A cl ose-upvi ew of A show sthe l argeri ghtcran i all obarpul monary
vein /y, relativeto the artery fa).
428 NE CKA ND TH OR AX -C OMP AN IO AN
N IM ALS

Figure 33-13, Lateralview of the thoraxof a g-month-old,neutered

femal e poodl e.N ote the l ack of opaci tyi n the l ung l obes due to
hypovascularity.
Tetralogyof Fallotwas confirmedat necropsy.

; ,,,11!1,,.
.iiilt
t::):l{j::::t:)

Figure 33-14, /, Lateralview of the thorax of a 6-year-oldmale

Dobe r m a np i n s c h e rN . o te th e e n la r g e m e not f th e r ig h t cr a n ia l obar
vein in comparisonwith the artery.There is loss of marginatlonof the t))).:.,1
v as cu l a t u raen d i n c r e a s ed lu n gp a r e n ch ym a o lp a cityd u e to h e a r tfai l ure ,,iiAl
wit h p u l m o n a r ve d e m a .B , A clo se - u pvie w sh o wsth e e n la r g e dcrani al ::..::')).:
.:
lobarpulmonarvvein (arrows)wilhloss of distinctmarginationDiagno- B,,''i,liil
y le ft h e a r tfa ilu r e .
s is :d i l a t o r yc a r d i o m y o pa thwith l9lrr.ii6l
 The PulmonarvVasculature 429

References A. Pulmonary lobar arterial enlargement.

l. Ettinger Sl, Suter PF: Radiographic examination. In Ettinger SJ, Suter PF (eds):
Canine Cardiology. Philadelphia, WB Saunders, 1970.
2. Evans HE: The respiratory apparatus. In Evans HE (ed): Miller's Anatomy ofthe
Dog. Philadelphia, WB Saunders, 1993.
3. Ruehl \,VW, Thrall DE: The effect of dorsal versus ventral recumbency on the
radiographic appearance ofthe canine thorax. Vet Radiol 22:10, 1981.
4. Thrall DE, Losonsky JM: A method for evaluating canine pulmonary circulatory
dlnamics from survey radiographs. J Am Anim Hosp Assoc 12:457,1976.
5. Rawlings CA, Lewis Rn, McCall JW: Development and resolution of pulmonary
arteriographic lesions in heartworm disease.I Am Anim Hosp Assoc 16:17, 1980.
B. Pulmonary lobar venous enlargement.
C. Both pulmonary lobar arterial and venous enlargement.
D. Normal pulmonary lobar vasculature.
2. This lO-year-old, spayedfemale, German shepherd dog is exer-
cise intolerant. The most accurate assessmentof the Ieft lateral
recumbent thoracic radiograph (Fig. 33-16) is:
A. Right cranial lobar pulmonary artery enlargement.
B. Right cranial iobar pulmonary vein enlargement.
C. Normal size of right cranial lobar pulmonary artery and

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.

5. Pulmonary arteries and veins may be reduced in size with

Answers begin on page727. which of the following?
A. Heartworm disease
n Ouestions B. Severeblood loss (hypovolemia)
C. Aelurostrongylus
l. This 9-year-old, neutered male, mixed canine has a cough
and is exercise intolerant. The most accurate radiographic sign 6. Which statement is accurate?
description of the left lateral recumbent (Fig. 33-15,4.)and dorso- A. On the lateral thoracic view, the large left pulmonary artery
ventral (Fig. 33-158) thoracic views is: is dorsal to the trachea.

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,
including puimonary diseasesthat cause (1) increased opacity,
(2) hlperlucency, (3) pulmonary mass lesions, and (4) calcified
pulmonary lesions.
I lncreased opacity
It is customary to describethe radiographic signs of pulmonary
diseasesthat cause increasedopacity in terms of the anatomic
divisions of the lung. The three categoriesof radiographic signs
(patterns)describedhere are bronchial, interstitial,and alveolar.
Bronchial pattern
Increasedvisualizationof bronchial walls constitutesthe bronchial
pattern of pulmonary disease.This may result from calcificationof
the bronchial cartilage (which is a normal age-relatedchange) or
thickening of the bronchial wall or peribronchial tissues.
Caicification of the bronchial wall causesan increase in opacity
but not in thickness(Fig. 3a-l). It is common among middle-aged
and old dogs and is not significant.In catswith bronchial disease,
multifocal pulmonary calcificationmay be observedas a result of
calcification of the peribronchial mucous glands or broncholithi-
asis.r Opaque foci compatible with calcification of peribronchial
mucous glands in cats may also be observed in cats without
respiratory signs; hence, this too can be an incidental finding
$ig.3a-2).
The key radiographicsign ofbronchial diseaseis a changein the
cross-sectional appearanceof the bronchus from a thin circle to a
thick circle of the samediameter (Fig. 3 -3). This appearancemay
occur as a result of bronchial mucosal thickening, debris in the
lumen, hyperplasia of the peribronchial glands, or peribronchial
infiltration by fluid or cells.Increaseddiameterof the lumen (with
or without thickening of the wall) indicates bronchiectasis. It is
frequently easier to recognize bronchial thickening when the af-
fected bronchus is seen end on rather than side on becauseoarallel
linear structureson a thoracic radiograph could representbronchi
Figurc 3/r-1. Bronchialcalcification.Detail of a lateralradiographof an aged
dog i n w hi ch the w al l sof the pri nci pal
cal ci fi cati on.
Table 34-1. Differential diagnosis of the bronchial
pattern
Bronchialcalcification
Chronic bronchitis
Allergic
Irritant
Parasitic,e.9., aelurostrongylosis
Peribronchialcuffing
Edema
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
Bronchopneumonia
or vessels.These alternatives may be distinguished by tracing the
linear structures peripherally-adjacent arteries and veins diverge
in the periphery of the lung, whereas bronchial walls converge is
the bronchi become progressively smaller., Also, as is shown in
Figure 34-3, the pattern of branching appears different-vessels
produce solitary branchesand bronchi produce paired branches.
Thickening of the bronchus is most often associatedwith chronic
inflammation or hypersensitivity; hence, the principal differentiai
diagnosesfor a diffuse bronchial pattern ar. ihronic bronchitis3,a
(Fig. 34-4), pulmonary eosinophilicinfiitrates,5-7 and parasiticin-
festation, such as aelurostrongylosis.sIn some instanceslinfiltration
of the peribronchial tissuesby edemaeor by inflammatory cells mav
produce the appearanceof bronchial thickening on radiographi;
therefore,peribronchial edema (e.g.,as a result bf cardiacitrsufn-
ciency, lymphatic obstruction, or acute allergic or inflammatory
pulmonary conditions) and bronchopneumoniamust also be con-
sideredas differentialdiagnosesof the bronchial pattern (Table34-
'
Bronchialdilation and lossof the normal taperingand branching
space between pulmonary vesselpairs are signs ol bronchiectasii
(Fig. 34*5).10Bronchiectasisis not easily recognizedon survey
radiographs; hence, this diagnosis may require bronchography for
confirmation.lr-r3
bronchiare di sti nctl yopa queas a res ul iof
4:ll
432 NE CKA ND T H OR AX -C OMP AN IO A
NN IMA LS

Figure 34-2. Lateralthoracrcradograph of a cat in which there

are mul ti pe smal opaquefoci scatteredthroughoutthe ung. Thi s
appearance i s compati bl w of the peri bronc higl
e i th cal ci fi cati on alands .

Interstitial patterns becauseof the partial collapseand increasedradiographicopacity

The interstitium is the name given to the non-air-containing ele-
ments of the lung, excluding the macroscopicblood vessels.The
interstitium includesthe alveolarseptum, the interlobular septum,
and microscopicblood vessels.Although detailedclassificationsof
interstitial patternshave been developed,they may be more simply
classifiedas nodular or unstructured, and localized or diffuse'o
(Tables 34*2 and 34-3).
Nodular interstitial Pattern
Pulmonary nodules,clustersof cells that expand and displacethe
adjacentlung, may be first recognizedradiographicallywhen they
reach 4 to 5 mm in diameter. Nodules smaller than this must
summate with each other before they are visible radiographically.
Nodules in the dependentlung may not be seen radiographically
ofthat lung.r5Focal opacitiessuperimposedon the lung that could
be pulmonary nodules must be distinguished radiographicaliy from
normal pulmonary vesselsseenend on and from foci of heterotopic
bone that occur frequently in the lungs of older, usually large-
breed, dogsr6(Fig. 3a-6).
Pulmonary vesselsseenend on:
. Usually occur closeto vesselsseenside on
. Are lessnumerous in the periphery of the lung
. Are never larger in diameter than the nearestside on vesselbut
are more opaque because,as a result of their orientation, they
representa greaterthicknessof tissue.
In contrast,pulmonary nodules:
. Are not consistentlyassociatedwith vessels

\
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.

D V Br o nchi ectasi/Ds i ncreasesbronchi al

wh e n vi ew edsi deon.
di ameter;a vari abl ebronchi al di ametermay al s o be apparent
 The C ani neand FelineLunq 433

Figurc 3/t4. Lateralthoracicradiographof a middle-ageddog with

c h r o n i cc o u g h a t t r i b u ta b le
to b r o n ch itis. T h e r e is a str ikin gbronchi al
p a t t e r nw , e l l s e e no ve r lyin thg e h e a r t,a s a r e su lto f th icke n e dbronchi al
w a l l s .N o t e t h a t t h e p u lm o n a r y
ve sse lsa r e b a r e lyvisib le a, common
f i n d i n gi n d o g sw i t h s e ve r eb r o n ch iadl ise a se .

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

Figure 3tI-6. A, Detailof a lateralthoracicradiographn which pulmo-

nary nodulesare visible,These nodules(some indicatedby arrowheads)
are largerthan the adjacentpulmonaryvessels(smal/arrowsland occur in
peri pheralparts of the l ung w here vessel sare normal l ytoo s mal l to be
seen radiographically. B, Pulmonaryvesselsviewed end on (smallarrows)
are effectivelythicker than soft-tissuenodulesof the same diameter,so
they appearmoreopaque.A s i n thi s i nstance, they are most c l earl yv i s i bl e
nearthe pul monaryhi l us,w here the vessel sare l argest.C , F oc iof pul rno-
naryheterotopibone c aredi sti ngui shed
from vessel sor soft tl s s uenodul es
by thei rvari abl eshapeand speckl edopaci ty.
 The C ani neand Fel ineLuno 435

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
. May be small or large regardlessof their location within the lung;
hence, pulmonary nodules may be recognizedwith certainty
when they are larger than adjacent blood vessels
Foci of pulmonary heterotopicbone:
. Are usually small with a speckledopacity
. Are irregularly shapedon closeinspection
Pulmonary nodulesmay be solitary or multiple, solid or cavitary
(see Thble 34-2). Pulmonary nodules may have distinct, smooth
margins or may have indistinct margins and tend to coalesce,
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
metastases. The sensitivityof radiographyfor pulmonary metastasis
detectionhas been estimatedat 650/oto 97o/o.t7-22
There is evidence
that a standard two-projection thoracic radiographic study (e.g.,
right lateral and dorsoventral views) is adequate for detection of
pulmonary metastasis";however,depending on their position in
the lung, lesions can be missed using this approach.,3Another
recommendation,which reflectsthe importanceof detectingmetas-
tasis, is to obtain three thoracic radiographs (e.g., both left and
right lateral and dorsoventral or ventrodorsal views) whenever
malignant neoplasia is suspectedclinically.
Distinguishingthe various causesof pulmonary nodules can be
challenging because there is considera-bleoverlap in the radio-
graphic appearanceof tumors (Fig. 34-7),r'. te 21'-24 2s granulomas
(Fig. 34-8),"-3' and abscesses(Fig.34-9).,, Also, a fluid- or mucus-
filled bronchus could be confusedwith a nodule in some instances
(Fig. 3a-10). The pulmonary lesions of acute paragonimiasisap-
pear radiographicallyas multiple, poorly circumscribed nodules
that range from I to 4 cm in diameter; subpleural air-filled cavities
and bullae (often septated)developin chronic infection.3a
Unstructured (hazyl interstitial patterns
This categoryincludesa large number of radiographrcappearances
that share two features: increased lung opacity and obscured, but
not obliterated,puimonary vasculature.laUnstructured (hazy) in-
terstitialpatternsmay include linear (reticular)3'and reticulonodu-
lar comPonents.
A wide variety of causesmust be consideredwhen a diffuse, hazy
interstitial pattern is interpreted (see Table 34-3). These include

Figure 3tI-8. Lateralthoracicradiographof an 8-month-oldRetriever

w i t h c o u g ha n d e x e r cisein to le r a n ce T.h e r ea r e se ve r aia
l r g ep ul monary
no d u l e sa n d a m o d e ra tein te r stitiain filtr a tem , a in lyin th e d o rsall ung
f i e l d s .T h e c a u d a tl r a c h e ais slig h tlyn a r r o w,co m p a tib lewith compres-
s i o n b y e n l a r g e dt r a ch e o b r o n ch ia lym
l p hn o d e s.T h e r eis e n largement
o f t h e r i g h t v e n t r i c le .Ciin ico p a th o lo gte icsts su p p o r te dh e artw orm
d i s e a s ea, n d t h e p u l mo n a r vle sio n sr e so lve da fte rtr e a tm e n w t i th ant-
h e l m i n t i c sF. i n adl i a g no sis: h e a r two r m - a sso cia e teodsin o p h ilic
pneumo-
nrtrs.
436 NE CKA ND T H OR AX -C OMP AN IO AN
N IM ALS

Figure 3/r-9. Close-upof the caudodorsallung field, in which a poorlymargin-

ated cavitatedlung mass (arrows)can be seen. Primarylung tumor was sus-
pected, and lobectomywas performed;however,histologicexaminationindi-
catedabscesssecondarvto septic pulmonarvinfarction.

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.

Figure 3tk11. Dorsoventral thoracicradiograph of a dogwith chronicrenal
insufficiency.
Thereis a bilateral
interstitial
infiltrate
mostmarkedin thecaudal
lunglobes.Histopathologic
examination of the lungrevealedlesionscompati
blewithuremicpneumonitis.
nonpathologic factors such as an underexposed radiograph, a ra-
diograph made during expiration rather than peak inspiration, lack
of adequatelung inflation associatedwith obesity, and superimpo-
sition of the lung by pleural fluid. Various systemic diseasesthat
affect the lung secondarily may also cause interstitial patterns-for
example,uremia (Fig. 34-ll). In some patients,knowledgeof the
history and clinicai signs aids interpretation. For example, blunt
thoracic trauma, near-drowning,'6 and smoke inhalation3Tcan pro-
duce similar diffuse, hazy interstitial patterns, but are readily diag-
nosed if an accurate history is available.
Certain localized, unstructured interstitial patterns may also re-
flect bronchial disease.For example,bronchial foreign bodies (usu-
ally nonopaque plant materials such as foxtails) are usually diag-
nosed by the interstitial infiltrate they stimulate around the
bronchus rather than by direct visualization (Fig. 34-12).38The
right caudal lobe is the most common site of bronchial foreign
bodies in dogs.
Some diseasesmay produce either nodular or hazy interstitial
patterns depending on factors such as etiologic agent, duration,
and severity; examples include mycotic pneumonia (Fig.
34-131,zo'tz'tz'sqr metastaticneoplasia(Fig. 34-14),t?'te 21'27' 42and
a3'an
dirofilariasis.3r'
Alveolar pattern
The alveolar pattern is a radiographic sign of diseasesthat displace
air from the distal air spacesof the lung (hence, it is also referred
to as the air space pattern). Lobar collapse and atelectasis,fluid
accumulation, and celluiar infiltrates (or combinations of these)
may produce the alveolar pattern. The radiographic signs of distal
air space disease are a relatively homogeneous increase in lung
opacity and the air bronchogram.a5Air bronchograms represent air
in the bronchial lumen, surrounded by a relatively homogeneous
The C ani neand Fel i n eLunq 497
soft-tissueopacity; the bronchial wall and the adfacentblood vessels
are not visible (Fig. 34-15). When the bronchus is also filled with
fluid or cells, the entire affected lung lobe may appear homoge-
neous and must be distinguished from a mass.
An alveolar pattern may be patchy or diffuse and may change its
appearance relatively quickly, particularly when it reflects fluid
accumulation in the lung. Changesin the severity and distribution
of fluid in the distal air spacesof the lung tend to occur more
quickly than movements of cellular infiltrate. When a Dulmonary
infiltrate is identified radiographically and the differential diagnosis
includes pulmonary edema, this possibility may be tested by re-
peating the radiographs after l2-hour diuresis-if edema was the
cause, a marked decreasein infiltrate will become apparent (Fig.
34-16). Other possible causesof infiltrate, such as bronchopneu-
monia or hemorrhage, are unlikely to change appearancesignifi-
cantly in such a short period of time. In fact, in these cases,a time
lag between the onset of clinical signs and the radiographic signs
of distal air spacediseaseis often observed, and a similai time 1ag
may occur during healing. For example,in the caseof consolidation
as a. result of bronchopneumonia, the radiographic lesion may
persist for severaldays despite obvious clinical improvement.
The principal differential diagnoses for the alveolar pattern in
-
dogs are summarized in Table 34-4. The most common causesare
pulmonary edema, bacterial bronchopneumonia, and hemorrhase.
Pulmonary edema is most often associatedwith left-sided cardiac
failure (see Chapter 32), but it can also occur as a sequel to
conditions affecting the central nervous system,such as epiltpsy or
electrocution.a6'a7 Pulmonary edema in dogs frequently is- most
marked in the caudal lung lobes (Fig. 3aaD and is usually sym-
metrical in distribution, whereas pulmonary edema in cats has a
more variable distribution, often appearing in asymmetrical
patches and often in the ventral part of the lung, where it may
mimic bronchopenumonia (see Fig. 34-17). Air bronchograms are
less often seen in cats with pulmonary edema than in dogs with
comparableedema.
Pulmonary consolidation associatedwith bacterial bronchopneu-
monia typically affects the ventral part of the lung and often is
asymmetrical.Bronchopneumoniaresulting from aspiration (e.g.,
se99ll_dalyto megaesophagus)is frequently localized to the right
middle lobe. The distribution of pulmonary hemorrhage is vaii-
able, depending on the cause.Hemorrhage associatedwith trauma
often occurs on the same side of the body as the impact, and
thoracic wall lesions, such as rib fractures, mav be visi6le radio-
graphically adjacent to the pulmonary lesion. For example, hemor-
rhage secondary to coagulopathy such as occurs in coumarin ro-
denticide toxicity may have a patchy or generalized distributionas
and may be accompanied by signs of pleural and tracheal hemor-
Table 3th4. Differential diagnosis of alveolar patterns
Localized
Bronchop neu mo n ia
Edema
Hemorrhage
P r i m a r yl u n g t u m o r
Pulmonarymetastasis
Lobar collapseor atelectasis
Airway obstruction,e.g., by mucus, foreign body
Secondaryto pleuraleffusion
Compressionby adjacentlesion
Dirofilariasis
Pulmonaryinfarct
Diffuse
S e v e r eb r o n c h o p n e u m o n i a
Severeedema
Severehemorrhage
Near-drowning
Smokeinhalation
Terminalparaquattoxicity
4 38 NE CKA ND T H OR AX -C OMP AN IOAN
N IM A LS

Figure 3/l-12. A young dog had a sudden-onset, persistentcoughfor

severalweeks. Lateral/A/ and ventrodorsa18)thoracicradiographs were
o b t a r n e dA. m a r ke dlo ca lize din te r stitiar ln filtr a te is presenti n the ri ght
c a u d a l o b e .En d o sco p rye ve a le da fo xta illo d g e dln the ri ghtcaudall obe
b r o n c h u sM l r e ig nb o de s in d o g s a r e nonopaque
. o sl b r o n ch iafo and are
n ly b e ca u seo f th e in fitrate that deveops
d e t e c t e dr ad r o g r a p h icaolly
a r o u n dt h e a ffe cte db r o n ch u s.Wh e n th is d o g wa s re-radi ographed 3
, e o u lm o n a r vln f ltr a teh a d r e sove d .
w e e k s l a t e r th

,sl

Figure 34-13, A, Lateralthoracicradiographof a dog with cryptococcosis in which a subtle,hazyinterstitralpatternand enlargedtracheobronchial

lymph nodes
When so manysmal nodul es are present,the superi mposi ti on
(a r r o w c) a nb e s e e n .B , M icr o n o d u lanr te r stitiapl a tte r nd u e to b astomycosi s. l eadsto c oal es c enc e
of o p a c i t i e tsh a t o b s cu r e su n d e r lyin p
g u lm o n a r str
y u ctu r e s.
 The C ani neand Fel ineLung 439

Figure 34-14. Reticularinterstitialpattern in the caudal lobes of

a cat with metastaticfibrosarcoma.A diffuse pattern of pulmonary
metastasisis observed.in a proportionof cats, usually those with
m a m m a r yc a r c i n o m a .

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 34-19. Lesronsthat result in al-

t e r e d l o b a rv o l u m ea r e o fte n d ia g n o se dr a -
d i o g r a p h i c a lol yn t h e b a siso f a m e d ia stin a l
sh i ' t . l h , s d i a g r a mo e p ictsth e e t' e ct o f a
m a s s ( i e f i , m ) , a c o nso lid a terdig h t m id d le
lobe that has not changedin volume /cen-
ter),ard a collapsedr;ghrrriddte ooe lright).
N o t e t h a t r e d u c e dvo lu m e o f a u n g lo b e
m a y p r o d u c ea m e d ia stin ash l iftto wa r dth e
le s i o n a , l t h o u g ht h i s e ffe ct is o fte n r e d u ce d
b y a r e d i s t r i b u t i oonf p le u r aflu
l ida r o u n dth e
c o l l a p s e dl o b e .
442 NE CKA ND T H OR AX -C OMP AN IOAN
N IM ALS

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?

Figure 3tl-22. Lateralthoracicradiographof a Rottweilerguard dog

re s c u e df r o m a b u r n in gwa r e h o u sea fe w h o u r s p r e vio u sly. The dog
was in respiratorydistressand died a few hours after radiography. This
ra d i o g r a pihs a n e x a m p leo f a m ixe dp u lm o n a r yp a tte r nwiti pi omi nent
bronchialwalls (blackarrows);dilluse, hazy interstitialinfiltrare;and pe-
ripheralalveolarpattern with air bronchograms(white arrowd. fhese
si g n sa r e t y p i c a lo f s mo ke in h a la tio nth
; e r a d io g r a p h sig
ic n s refl ectthe
severe effect of smoke on the bronchialmucosaand surfactantactivity
t h a t l e a d st o b r o n c h itis,
b r o n ch iam l n d p e r iva scu laerdema,ate-
l u co sa a
le c t a s i sa, n d a l v e o l ahe
r morrhage.

I
i

Figure 34-23. Lateralthoracjcradiographof a 1-year-oldretriever

with exerciseintoleranceand slightlyincreasedrespiraioryeffort.There
are severalthi n-w al l ed,
gas-fi l l ed
bul l aei n the crani o v entral
l unq fi el d.
Fi naldi agnosi s:
congeni tal bul l ousemphvsema.
44 NE CKA ND T H O R AX -C OMP AN IO AN
N IM A LS

Figure 34-24. Emphysemaassociatedwith chronicbronchitisin a 6-year-

old cat with a historyof graduallyworseningdyspneafor 3 years. In lateral
/// and ventrodorsal/Bi radiographs,there is a coarse,patchy pulmonary
i n f i l t r a t et h a t is d istr ib u te dm a in lyto wa r dth e p e r ip h eryof the l ung,a few
t h i c k e n e dr i n g sh a d o ws,a n d n u m e r o u sfo ca l r o u n d edl ucentl esi ons.Thi s
a p p e a r a n c ies co m p a tib lewith e m p h yse m aco m p licati ng chroni cbronchi al
d i s e a s e(.R a d io g r a p hco s u r te syo f Da vidBo e r sm aM , RC V S ).

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

Figure 34-26. Use of ultrasonography to examine a pulmonarymass.

D etai lof a dorsoventral
radi ograph peri ph-
/A / i n w hi ch a w el l -ci rcums c ri bed
eralpul monarymass i s vsi bl e.The mass l i escl oseto the ri bs wi thoutany
i nterposedaeratedl ung. 8, U l trasoundi mageof mass reveal sa rel ati v el y
thi n-w al l ed
and anechoi ccentralcavrty.D i fferenti al
di agnoses for thi sappear-
ance shoul di ncl udebronchogenicyst,c pul monaryabscess,ano neoptas m
with infectedor necroticcenter.Ultrasound-guided aspirationof the cavity
producedexudatesuggesti veof an abscess;how ever,the fi n al di agnos i s
w as bronchi acarci noma.

I Pulmonary mass lesions
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
than "nodules" and, becauseof their size, often produce a "mass
effect" such as displacementof adjacentorgans.Unilateral pulmo-
nary massesoften causea mediastinal shift toward the contralateral
side (seeFig. 3a-19). When there is no mass effect and the shape
and location of the lesion correspond to a specific lung lobe,
consolidationor lobar collapsewith local pleural fluid accumula-
tion must alsobe considered.When thesethree possibilitiescannot
be distinguishedradiographically,some alternaiiveimaging mod-
ality such as ultrasonography'n,un(Fig. 3a-26) or computed tomog-
raphf'8 may be useful. The differential diagnosis of pulmonary
massesis as stated for nodules in Thble 34-2. primarv neoDlasiais
the most common causeof a pulmonary massin the dog or cat.
I Galcified pulmonary lesions
A variety of pulmonary lesionsmay calcifu.un,70 Thesecalcifications
may be classifiedas focal or diffuse (Table34-6). Many instancesof
focal pulmonary calcification in the dog or cat represent incidental
findings; however, calcification is a notable featuie of Histoplasma
granulomas in dogs3eand is observedin a small proportion of
primary pulmonary neoplasmsr'(Fig. 3a-27). Barium sulfate sus-
pension, which may be deposited in the lung during bronchogra-
phy or when an upper gastrointestinal contralt study is attempied,
may be confusedwith calcificationbut is more opaquetFig.:+-
28).

Tahle 34-6. Galcified pulmonary lesions

Focalor multifocal Diffuse

Bronchialcalcification Hyperadrenocorticism
Calc if iedper ibr onc hialm uc ous g l a n d s Hyperparathyroidism
Br onc holit h
ias is C h r o n i cu r e m i a
Heterotopicbone ldiopathic
G r anulom a- e. 9. ,c anine ( not f e l i n e ) h i s t o p l a s m o s i s
Pr im ar ylung t um or
Osteosarcoma metastasis
Aspiratedbarium sulfate
4 46 NE CKA ND T H OR AX -C OMP AN IOA
NN IMA LS

Figure 3tI-27. Detail of a lateralthoracic radiographof a dog wlth a

parti al lcal
y ci fi ed
pul monary
mass.H i stol ogidi
c agnosiw
s as c hondros arc oma.

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 .

References
1. Allan GS, Howlett CR: Miliary bronchiolithiasis in a cat. T Am Vet Med Assoc
162:214, 1973.
2. Myer CW: Radiography review: The vascular and bronchial patterns ofpulnonary
disease.Vet Radiol 21:156,1980.
3. Mantis R Lamb CR, Boswood A: Assessmentof the accuracy of thoracic radiogra-
phy in the diagnosis of canine chronic bronchitis. J Small Anim Pract 39:518, 1998.
4. Moise SN, Wiedenkeller D, YeagerAE, et al: Clinical radiographic, and bronchial
cytologic features of cats with bronchial disease:65 cases( 1980-1986). J Am Vet Med
Assoc 194;1467,1989.
5. Suter PR Lord PF: Thoracic Radiography; A Text Atlas of Thoracic Diseasesof
the Dog and Cat. Wettswil, Switzerland, PF Sutea 1984, p 570.
6. Corcoran BM, Thoday KL, Henfrey JI, et al: Pulmonary infiltration with eosino-
phils in 14 dogs. J Small Anim Pract 32:494,1991.
7. Moon M: Pulmonary infiltrates with eosinophilia. J Small Anim Pract 33:19, 1992.
8. Losonsky JM, Thrall DE, Prestwood AK: Radiographic evaluation of pulmonary
abnormalities after Aelurostrongylus abstrusus inoculation in cats. Am J Vet Res
44:478, 1983.
9. Staub NC, Nagano H, Pearce NL: Pulmonary edema in dogs: Especially the
sequenceof fluid accumulation in the lungs. J Appl Physiol 22:227, 1967.
10. Myer CW, Burt lK: Bronchiectasis in the dog; Its radiographic appearance.J Am
Vet Radiol Soc l4:3, 1973.
11. Douglas SW: The interpretation of canine bronchograms. J Am Vet Radiol Soc
15:18,1974.
12. Webbon PM, Clarke KW: Bronchography h normal dogs. J Small Anim Pracl
18t327,1977.
13. Walter PA: Non-neoplastic surgical diseasesof the lung and pleura. Vet Clin North
Am Small Anim Pract 17:359,1987.
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 .
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
A sso c2 3 :3 8 1 ,1 9 8 7 .
16. Reif JS,RhodesWH: The lungs of ageddogs:A radiographic-morphologiccorrela-
tion. I Am Vet Radiol Soc 7:5. 1966.
17. Suter PF, Carrig C, O'Brien TR, et al: Radiographicrecognition ofprimary and
metastaticpulmonary neoplasiaof dogs and cats.J Am Vet Radiol Soc 15:3, 1974.
18. Lang J, Wortnan JA, Glickman LT, et al: Sensitivity of radiographic detection of
lung metastasesin the dog. Vet Radiol 27:74,1986.
19,'fiemessen I: Thoracic metastasesof canine mammary gland tumors: A radio-
graphic studl Vet Radiol 3A249,1989.
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
Vet Med Assoc 200:1535,1992.
21. Hammer AS, Bailey MQ, Sagartz JE: Retrospective assessmentof thoracic radio-
graphic findings in metastatic canine henangiosarcoma. Vet Radiol Ultrasound
34:235,1993.
22. Barthez PY, Hornof WJ, Theon AP, et al: Receiver operating characteristic curve
analysis of the performance of various radiographic protocols when screening dogs
for pulmonary metastasis.J Am Vet Med Assoc 204:237, 1994.
23. DeHaan CE, PapageorgesM, Kraft SL; Radiographic diagnosis. Vet Radiol Ultra-
s o u n d 3 2 :7 5 ,1 9 9 1 .
24. Barr FJ, Gibbs C, Brown PJ: The radiological features of prinary lung tumours
in the dog: A review of thirty-six cases.j Small Anim Prcct 271493,1986.
25. Koblik PD: Radiographic appearanceof primary lung tumors in cats. A review of
41 cases.Vet Radiol 27:66, 1986.
26. Barr F, Gruffydd-Jones TJ, Brown Pl, Gibbs C: Primary lung tumours in the cat.
J Small Anim Pract 28:1115,1987.
27. Miles KG, Lattimer JC, Jergens AE, et al: A retrospective eyaluation of the
radiographic evidence of pulmonary metastatic diseaseon initial presentation in the
dog. Vet Radiol 3l:79,1990.
28. Shaiken LC, Evans SM, Goldschmidt MH: Radiographic findings in canine nalig-
nant histiocltosis. Vet Radiol Ultrasound 321237,1991.
29. Silverman S, Poulos PW, Suter PF: Cavitary pulmonary lesions in animals. J Am
Vet Radiol Soc 17: 134. 1976.
30. Ackerman N, Spencer CP: Radiologic aspectsof mycotic diseases.Vet Clin North
An Small Anim Pract 12:174, 1982.
The C ani neand FelineLunq r yn
31. Calvert CA, Mahaffey MB, Lappin MR, et al: pulmonary and disseminated eosino-
philic granulomatosisin dogs. J Am Anim Hosp Assoc 24:311,198g.
32. Walker MA: Thoracic blastomycosis: A review of its radiographic manifestations
in 40 dogs. Vet Radiol 22:22,1981.
33. Suter PF, Lord PF: Thoracic Radiography: A Text Atlas of Thoracic Diseasesof
the Dog and Cat. Wettswil, Switzerland, pF Surer, 1984, p 595.
34.- Pechman RD: The radiographic features of pulmonary paragonimiasis in the dog
and cat. J Am Vet Radiol Soc 17:182, 1976.
35. Reif JS, Rhodes WH: Linear opacities in canine thoracic radiographs. An Vet
J
Radiol Soc 9:57, 1968.
36. Farrow CS: Near-drowning in the dog. ) Am Vet Radiol Soc 18:6,1977.
37. Tams TR, Sherding RG: Smoke inhalation injury. Comp Contin Educ pract Vet
3:986,1981.
38. Dobbie GR, Darke PGG, Head KW: Intrabronchial foreign bodies in dogs. J Small
Anim Pract 27:227, 1986.
39. Burk RL, Corley EA, Corwin LA: The radiographic appearance of pulmonary
histoplasmosis in the dog and cat: A review of 37 .ur. histoii.r. J Am Vet Radiol Soc
l9:2. 1978.
40. Wolf AM, Green RW: The radiographic appearance of pulmonary histoplasmosis
in the cat. Vet Radiol 28:34,1987.
41. Millman TM, O'Brien TR, Suter pF, et al: Coccidioidomycosis in the dog: Its
radiographic diagnosis. J Am Vet Radiol Soc 2O:50, 1979.
42. Forrest LJ, Graybush CA: Radiographic patterns of pulmonary metastasis in 25
cats.Vet Radiol Ultrasound 39:4, 1998.
43. Ackerman N: Radiographic aspects of heartworm disease.Semin Vet Med Surs
2:15, 1987.
44. CarlisleCH: Canine dirofilariasis:Its radiographicappearance.Vet Radiol 2l:123,
1980.
My:, W: Radiography review: The alveolar pattern of pulmonary disease.I Am
15.
Vet Radiol Soc 20:10, 1979.
46. Lord PF: Neurogenic pulmonary edema in the dog. J Am Anin Hosp Assoc
l l :778,1975.
47. Kolata RJ, Burrows CF: The clinical features of injury by chewing electrical cords
in dogs and cats.J Am Anim Hosp Assoc l7:219, 1981.
48. Berry CR, Gallaway A, Thrall DE, et al: Thoracic radiographic features of anticoag-
ulant rodenticide toxicity in fourteen dogs. Vet Radiol Ultiasound 34:391, 1993.
49. Kerr LY: Pulmonary edema secondary to upper airway obstruction in the dog: A
reyiew of nine cases.I Am Anin Hosp Assoc 25:207,19g9.
50. Moon ML, Greenlee PG, Burk RL: Uremic pneumonitis-like syndrome in ten
dogs. J Am Anim Hosp Assoc 22;687,1986.
5l._Parent C, King LG, Walker LM, van Winkle TI: Clinical and clinicopathologic
findings in dogs with acute respiratorydistresssyndrome: t9 cases(1985-1993).J Am
Vet Med Assoc 208:1419,1996.
52. Suter PF, Lord PF; Thoracic Radiography: A Text Atlas of Thoracic Diseasesof
the Dog and Cat. Wettswil, Switzerland, pF Suter, 1984, p 564.
53. Darke PGG, Gibbs C, Kelly DF, et al; Acute respiratory distress in the dog
associatedwith paraquat poisoning. Vet Rec 100:275, 1977.
54. Gee BR, Farrow CS, White RL Orr l: paraquat toxicity resulting in respiratory
distress syndrome in a dog. I Am Anin Hosp Assoc 14:256, l9jg.
55. Lord PR Gomez JA: Lung lobe collapse: pathophysiology and radiologic signifi-
cance.Vet Radiol 26:187,1985.
56. Robinson NE, Milar R: Lobar variations in collateral ventilation in excised dos
lungs. Am Rev Respir Dis 121:827,1980.
57. lohnston GR, Feeney DA, O'Brien TD, et al: Recurring lung lobe torsion in three
Afghan Hounds. .l Am Vet Med Assoc 184:842,1984.
58. Lord PR Greiner TP, Greene RW, et al: Lung lobe torsion in the dog. J Am Anim
Hosp Assoc 9:473, t973-
59. Stowater JL, Lamb CR: Ultrasonography of non-cardiac thoracic diseasesin small
animals.) Am Vet Med Assoc 195:514,1989.
60. Reichle JK, Wisner ER: Non-cardiac thoracic ultrasound in 75 feline and canine
patients.Vet Radiol Ultrasound 41:154,2000.
61. Moise SN, Spaulding GL: Feline bronchial asthma: pathogenesis,pathophysiology,
diagnostics, and therapeutic considerations. Comp Contin Educ pract Vet 3:1091,
198l .
62. Herrtage ME, Clarke DD: Congenital lobar emphysema in two dogs. ] Small Anim
Pract 26:453,1985.
63. Tennant BJ, Halwood S: Congenital bullous emphysema in a dog: A case reporr.
I Small Anim Pract 28:109,1987.
448 NECKAND THORAX-COMPANIONANIMALS

64. Chalifou A, Morin M, Lemieu R: Lipid pneumonia and severe pulmonary

emphysema in a Persian cat. Fel Pract 17(1):6, 1987.

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
Radiol ljltrasound 41:340, 2000.

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

2. List four nonpathologic patient factors that may adversely

affect thoracic radiographic quality.

3. A S-year-old male Rottweiler was lethargic and had an intermit-

tent cough for 3 weeks. Hematology and serum biochemistry re- and became dyspneic, There was mild pyrexia and neutrophilia.
sults were within normal ranges.Examine the dorsoventral thoracic Examine the thoracic radiographs in Figure 34-30A and B. Classiff
radiograph shown in Figure 34-29. Describe the lesion, and list the pulmonary pattern. What other relevant radiographic sign
your differential diagnoses. is present?

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

NECK AND THORAX-EOUIDAE

ffi CHAPTER

ffi35
ffi Larynx,Pharynx,
Airway
ffi ."J,l,Proximal
The laryngeal/pharyngeal region is commonly evaluated radio-
graphicallyby checkingthe size,shape,and position of each of its
parts against the norm (Figs. 35-1 and 35-2). However, more than
structural analysis is required for complete assessmentof this
anatomic region. Endoscopyhas provided valuable functional in-
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-
larly that which has been witnessedendoscopically.
It is the correla-
tion between radiographic abnormalities and endoscopicallyob-
served malfunctions that forms the basis for diasnosis in this
complex region.
I Complementary examinations
Pharyngography and esophagography
Pharyngographyand esophagography are performed to assesssus-
pected soft-palate and epiglottic dysfunction, as weli as swallowing
disorders.This procedure, performed by placing barium in the
mouth with a dose syringe followed immediately by radiography,
usually allows differentiation of pharyngeal from laryngeal maises;
it also enablesevaluation of the ability of the epiglottis to keep
ingestedmaterial out of the trachea(Fig. 35-3).
I The appearanceof
I laryngeal disease
In terms of what may be specificallyidentified in a radiographic
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
or spatialalterationsto thesestructuresconstitutethe basisfor the
radiographic signs of laryngeal disease.These signs include (1)
abnormalepiglotticpositionrelativeto the soft palate,(2) epiglottic
thickening or marginal irregularity, (3) decreasedepigloitii size
(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
Figure 35-2. Normalateraprojection
of the cervicaregionof the equine
trachea.
arytenoepiglotticfolds or corniculateprocesses,and (5) laryngeal
or paralaryngealmineralizationor gas.r
Acute epiglottiditis resulting from inflammation or infection
typically resultsin uniform enlargementas observedendoscopically
Nasotrachealintubation injury may causesim-
or radiographically.'?
ilar changes.3
Medium to large subepiglottic,epiglottic, and paraepiglottic
massescan alsobe radiographicallyidentified.Theselesions,partic-
ularly if of the subepiglottictype, may displacethe epiglottis in a
dorsocaudaldirection, effectivelyincreasingthe distancebetween
the epiglottis and the soft palate. Unfortunately, it is often not
possibleto establishthe etioiogy of such lesionsbecauseof their
radiographicsimilarity. Differential considerationsinclude subepi-
glottic cyst, granuloma,abscess, and rarely,tumor (Fig. 35-4).
Inflammation (especiallyif chronic), postsurgicalscarring, and
congenitaldisordersmay distort or otherwisealter the appearance
of the epiglottic and arytenoid tissues(Figs.35-5 and 35-6).'
Occasionally,a primary lesion such as a tumor may occur in
; ''
F "
. a:
r:iiiiltli:riii;
iil$ll].iilllllt
*i
.iilut lluu,iiiu:rriii:
.-:
. si
t, ii rt,,,i'rt,t.,iit9ll;
A B
Figure 354, A, Exampleof a subepiglotticmass,latera projection D ragnosi s:
Figure 35-3, Pharyngogram.
Thereis a argemassventralto the epiglottis
(largearrows)and
contrast
mediumwithinthe laryngea
l:odybmallarrows).
one of the arytenoepiglotticfolds, causingthe proximal part of the
larynx to be nearly formless and greatly increasedin opacity (Fig.
35-7). Likewise,a paraepiglotticmass or mass effect may distort
or obscurethe rostral part of the larynx (Fig. 35-8). Paralaryngeal
abscessation may occur secondaryto laryngealinfection. If fistu-
lation develops,the abscessmay drain into the larynx, its support-
ive content being replacedby air; this can produce a variety of
distinctivegas accumulations(Fig. 35-9).s
Epiglotticentrapmentmay or may not be detectableradiographi-
caily. Decreasedepiglottic size and altered shape and positioning
relativeto the soft palatesuggestentrapment;invariablesequential
imagesof the epiglottisdo likewise.6Epiglottic blunting and dorsal
displacementhave also been observedin associationwith entrap-
m ent.7,8
Laryngealmineralization may occur as a function of aging, or,
alternatively, may develop following laryngeal surgery or chronic
laryngealinflammation, arytenoid chrondritis, or arytenoid chon-
drosis (Fig. 35-10;.'0," Such dystrophic calcificationmay signify
Soft
p o l o t e- '
Subepiglotticobscess
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

Figure 35-9. Lateralprojecton of the gutturalpouches.There is an ovoid

gas accumul ati on P aral aryngeaal
dorsalto the l arynx.D i agnosi s: bs c es s .
Figure 35-7, Lateralprolectiono'f the laryngealregion.There is convexity
o pacty overal l
fo ld s a n d in cr e a se d
of t h e n o r m a l l yc o n c a v ea r yte n o e p ig lo ttic
o n th e ve n tr a lm a r g lno f the guttural
(t he s p h e r i c aol p a c i t ysu p e r im p o se d
pouc hf i e l di s i n c i d e n t a LDia Sq u a m o u sce Lca
) . g n o sis: l r cin o m a

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

subdivided into three regions: the nasopharprx, which constitutes

the major part of the cavity; the laryngopharprx, which is the
area immediately dorsal to the arytenoepiglottic folds; and the
oropharynx, the area ventral to the caudal aspect of the soft
palate, which is typically not visualized becauseoi its similarity to
surrounding tissue(seeFig. 35-1).
Dorsally, the pharynx is bounded by the paired guttural pouches,
readily identifiable by their large gas content. The larynx, discussed
,-,iillllll:,,riiiil:],
:lr''llll, previousiy, forms the caudal pharyngeal margin as well as a portion
'.'ti.tlt{i)
t'iiiil1llt.'iiilllll,,ill0lll
.: :?1
i111Sl
of the ventral border. The soft palate constitutes the remainder of
l$lllllllll,. ll,flllr,ll the ventral pharl'nx. The rostril aspect of the pharynx is radio-
lli*llllEllrlr'iii!|lr,-,ii11$l
graphically nonspecific, being a composite image of multiple con-
tiguous and overlappingstructuresor cavities(seeFig. 35-l). For
the purposes oforganizational simplicity, the pharl'ngeal cavity and
guttural pouches are discussedseparately.

The pharyngeal cavity

Radiographic indications of pharyngeal diseaseinclude decreased
gas content, alterations in size or contour, and changesin the size,
shape,or position of the soft palate.Reducedpharyngealvolume
is usually of an extrinsic nature, stemming from disease-induced
enlargement of surrounding structures, such as the guttural
pouchesand retropharyngeallymph nodes (Fig. 35-ll). Gunshor
wounds to the throat region may cause extensive pharyngeal and
parapharyngealbleeding as well as injury to the upper airway (Fig.
Figure35-1O. Lateral projection
of the laryngea
region.
Therearevertically 35-12).
oriented opacitiesdorsalto the aryngotrachealjunctionand m ld tracheal Parapharyngeal adenopathy often produces a distinctive
stenosis.Diagnosis:Dystrophiccalcification
caused laryngeal/para-convexity in the caudoventral margin of one or both guttural
by chronic
laryngealinflammation. pouches (Fig. 35-13). Radiographsmade during swallowing may
show the tongue filling the majority of the pharynx, thus mimick-
ing a pharyngealmass.ra
alteredlaryngealfunction, especiallywhen associatedwith enlarge- Dorsal displacement of the soft palate is usually associatedwith
ment, abnormal margination, or distortion of the arytenoid carti- organic or functional disorders of the larynx or pharynx (Fig.
lage.The term chondroma is usedto describean arytenoidmassef- 35-14). Occasionally,normal horsesmay have dorsal palatal dis-
fect.r2 placement; however, this is usually only an intermittent finding.
Potentially, any laryngeal disorder may lead to varying degrees When present radiographically, dorsal displacementshould be con-
of upper airway obstruction,rswhich may sometimesbe inferred
sideredabnormal until proved otherwise.Possiblelaryngealetiolo-
radiographicallyfrom pharyngealdistention or pulmonary overin-
gies include epiglottic hypoplasia,persistentepiglottic frenulum,
flation.
epiglottic scarring,and epigiottic entrapment by diseasedor mal-

I The appearanceof formed arytenoepiglotticfolds.

Pharyngeal causesof dorsal palatal displacement include palatal
I pharyngeal disease hypoplasia, palatal myositis, ninth and tenth cranial neuropathy,
The pharynx, as viewed in a lateral radiographicprojection, con- and pharyngitis;secondarycausesinclude disordersof the guttural
sists of a large, roughly rectangular, air-filled chamber that is pouchesand parapharyngealstructures.rs-I7 Dorsal displacementof

]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.

Figure 35-12. Lateral

projection
of the guttural
pouches.
Thereis decreased
pharyngeal
transparency
andmultiple bulletfragments.
Diagnosis:pharyngea
hemorrhage to gunshot
secondary wound.

the soft palate, without associatedlarlmgeal disorder, may be linked
to airway disease."
I The guttural pouches
The guttural pouches are large, thin-walled, air-filled extensionsof
the pharynx. Although readily visible becauseof their air content,
their superimposition and relative proximity afford minimal op-
portunity for radiographicseparation.Oblique projectionsmay be
of some use in partially separating the pouches, but only the
ventrodorsalview completelyeliminatessuperimposition.Accord-
ingly, assessment of the guttural pouches is usually based on one
or more lateral projections.'e
The radiographic signs of guttural pouch diseaseinclude in-
creasedor decreasedair content, increasedfluid, deformity, intra-
luminal mass, extraluminal gas, pharyngealcompression,and la-
ryngotrachealdisplacement.
One or both guttural pouches may be distended with gas, fluid,
or a combination (Fig. 35-15). With unilateral disease,the abnor-
mal pouch often compressesthe adjacent normal pouch to the
extent that it becomes invisible radiographically.rOSeveregaseous
distention, also known as tympany, is most frequently seenin foals
and young horses;its causeis speculative.The degreeof swelling is
often so great that the enlarged pouch compressesthe pharynx and
displacesthe larynx and proximal tracheaventrally. This dislocation
of the proximal part of the upper airway may severelyhamper
breathing (Fig. 35-16A and B). Subtotal fluid accumulationin ihe
guttural pouch is usually associatedwith a distinctive fluid level in
radiographs made with a horizontally directed x-ray beam (Fig.
35-L7). It is not possible,however, to distinguish the nature of the
fluid. Fortunately, the possibilities are few in number, with the two
primary considerationsbeing exudate(empyema)and hemorrhage.
Hemorrhage can result from erosion of the internal carotid
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,

Figure 35-15. Lateralprojectionof the gutturalpouches.Therels a greatlyenlarged

g u t t u r a lp o u c hf i l l e dwith a m ixtu r eo f flu id ,a ir ,a n d f o a tin gdebri s.The pharynxi s
s e v e r e l yc o m p r e s s eda,n d th e la r yn xa n d tr a ch e aa r e d isp la cedventral l ycausi ngnear
c o m p l e t eo b s t r u c t i ono f th e p r o xim aa ir wa y.Dia g n o sis:Ne cr oti cdi verti cul i ti s.
458 NE CKA ND T H OR AX -EOU ID A E

Figure 35-16. tale"al (A) and ventrodorsai18)Droiectionsof the

t h r o a t r e g io no f a yo u n g fo a l. T h e r e is g a s d tss ecti onof the l eft
g u t t u r apl ou ch ,with se ve r etr a ch e ad isp la ce m e nt ventral l y.
D i agno-
s i s : C o n g e n itaol b str u ctio no f th e p h a r yn g e aol p eni ngto the l eft
g u t t u r apl ou ch .

Figure 35-17- Air-fluidinterfaceresultingfrom guttura pouch infection(lateralproiection)

 Larynx,Pharynx,and ProximalAirway 459

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
foreign body, or gunshot.22 Exudatemay accumulatein the guttural
pouch secondaryto a ruptured retropharyngealabscess, a regional
streptococcalinfection, or outflow obstruction secondaryto steno-
sis of the pharyngealopening.'zr The pouch may also be infectedby
contaminatedinstruments,needles,or irrigating solutions.Mycotic
infection may extend to the adjacent stylohyoid bone, causing
bone deposition,destruction,and in severeinstances,a pathologic
fracture.2a Most infectionsare unilateral.25
Occasionally, gas or fluid levels are noted in proximity, but
external,to the guttural pouches(Fig. 35-18). Inferentially,a gut-
tural pouch origin should be considered,although other gas-con-
taining structures,such as the pharynx, larynx, and trachea,may
also leak air after perforation.With regardto the guttural pouches,
it is usually an infection that results in necrosisof the guttural
pouch wall and subsequentescapeof its gasand infectiouscontent.
Fistulas and sinusessometimesform and often are amenableto
sinography. Bacterial gas formation occurs rarely.
Intraluminal massesare identified occasionallyif they are of
sufficient size and are surrounded by air (Fig. 35*19). possible
causesof such massesinclude chondroids, inflammatory tissue
masses,and blood clots. Tumors may appear similarly; however,
they are rare.
Large volumes of luminal fluid may somewhat or entirely ob-
scure one or both guttural pouches.It may be especiallydifficult
to establishthe laterality of such lesions becausethey frequently
compressthe uninvolved pouch as well as the pharynx, larynx, and
proximal trachea(Fig. 35-20).
I Tracheal disease
The normal equine cervical trachea may be imaged sufficiently to
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
rings, and the annular ligaments (by inference, the space between
tracheal rings) (Fig. 35-2i; see also Fig. 35-2). The absenceot
alterationsof these normally visible shadowsform the radiologic
basisfor a diaenosisof trachealdisease.
Figure 35-21. Extraluminal gas escapingthe cranialcervicaltrachea3 hours
aspiration(lateralprojection).
after transtracheal
Primary trachealdisordersare only occasionallydetectedradio-
graphically. Tiacheal displacement, however, is common, usually
resulting from enlargementof the guttural pouch or the cervical
part ofthe esophagus,and may be readily appreciatedradiographi-
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
massesoccur occasionally.Most stenotic lesions are the result of
tracheotomy-induced scarring related to incorrect surgical tech-

Figure 35-22. Extraluminalgas escapingthe caudalcervicaltracheaafter a penetrating
w o u n d l l a t e r apl r o j e c tio n ) .
nique (see Fig.35-23).30 Deep cervical lacerations,penetrating
foreign bodies, and gunshot wounds may also lead to tracheal
scarringand stenosis.Luminal massesare rare, most being tumors
or foreign bodies.Trachealcollapsemay be congenitalor acquired,
and is often regional in nature. Based on the small number of
published reports, it is rare.''' " Trachealhypoplasiain the horse,
as in other domesticanimals,is associated with a uniformly dimin-
ished size, but unlike in other animals, laryngeal hypoplasia may
also be present.t'
I Diseases often associated
I with a normal-appearing
I radiograph
Pharynx
Pharyngeal lymphoid hyperplasia is radiographically recognizable
if the lymphoid plaques are very large and project into the pharyn-
geal cavity; otherwise, they are indiscernible from the rest of the
pharyngealsoft tissues.t'Likewise,pharyngealcysts are undetect-
F i g u r e 3 5 - 2 3 . L ate r a lp r o je ctio no f th e ce r vica ltr a ch e alregi on.
There is a tracheotomytube that has causedstenosisat the point of
in s e r t i o np; a r a t r a c h egaal s in d ica te d
le a ka g e .
Larynx,Pharynx,and ProximalAirway 461
able, unless they are sufficiently large and convex. The same may
be said for other pharyngeal masses,such as abscesses and granulo-
mas. Free pharyngeal fluid cannot be detected radiographically.
Larynx
In the horse, there frequently are no radiographic abnormalities
associated with epiglotticentrapment.Subsequentserialendoscopic
examinations of affected horses have shown varying degrees of
entrapment or, more usually,restrictedor limited epiglottic move-
ment (Fig. 35-24). These findings have usually been attributed to
a slight inward folding of the arytenoepiglottic folds. Thus, as
with any radiographic examination designed to evaluate altered
anatomy, the alteration must be of sufficient magnitude to be
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,
but also it should precedethe radiographic examination; the
chancesof finding a radiographic abnormality are thereby greatly
enhanced.
Laryngeal hemiplegia cannot be diagnosed radiographically, nor
can all but the most extreme epiglottic inflammations. Even this
4 G,2 NE CKA ND T H O R AX -EOU ID A E
, :,,,
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.
All but the largest thyroid tumors are radiographically invisible.3s
Noisy breathing, with or without distress,is one of the features
of hyperkalemic periodic paralysis, a genetic disease of Quarter
horses, including young foals. Although endoscopic examination
may reveal laryngeal spasm or paralysis, radiographs are likely to
appear normal.36'3t However, extreme muscular hypertrophy has
been known to cause external compression of guttural pouches,
with the resulting radiographic appearanceof a pharyngeal
m a s s . 38 '3 e
Trachea
Tracheitis has not been described radiographicallS with or without
the use of contrast medium. Tracheal fluid, even in large volumes,
is usually not detectable radiographically. Small luminal masses
(lessthan I cm) typically remain unidentified. Tiacheograms show
only major lesions and rarely identifr perforations, including those
that produce large volumes of extratracheal air.
References
l. Linford RL, O'Brien TR, Wheat JD, Meagher DM, et al: Radiographic assessment
of epiglottic length and pharlngeal and larlngeal diameter in the Thoroughbred. Am
I Vet Res44:1660,1983.
2. Barclay WR Phillips TN, Foerner lJ: Acute epiglottidis in a horse. J Am Vet Med
Assoc 181:925,1982.
3. Holland M, Snyder JR, Steffey ER Heath RB: Laryngotracheal irjury associated
with nasotracheal intubation in the horse. J Am Vet Med Assoc 189:1447, 1986.
4. Dixon PM, Railton DI, McGorum BC: Ventral glottic stenosisin 3 horses. Equine
Yet I 26:166, 1994.
5. Farrow CS, Barber SM: Pharlngeal abscesswith larlngeal fistulation in a horse
(What is your diagnosis?).J Am Vet Med Assoc 179:830, 1981.
6. Ferraro GI: Epiglottic entrapment. In White NA, Moore fN (eds): Equine Surgery.
Philadelphia, WB Saunders, 1990, p 236.
7. Butler JA, Colles CM, Dyson SJ, et al: Clinical Radiology of the Horse. London,
Blackwell Scientific Publications, 1993, p 347.
8. Dik KJ, Gunsser I: Atlas of Diagnostic Radiology of the Horse. philadelphia, WB
Saunders,1990,p 102.
9. Orsini PG: Xerographic examination. In Beech j (ed): Equine Respiratory Disor-
ders. Philadelphia, Lea & Febiger, 1991 p 12ir
10. Haynes PF, Snider TG, McClure JR, McClure JJ: Chronic chondritis ofthe equine
arytenoid cartilage.J Am Vet Med Assoc 177:1135,1980.
1 l. Cahill JI, Goulden BE: Diseasesof the larynx. In Colahan PT, Mayhew JG, Merritt
AM, Moore JN (eds): Equine Medicine and Surgery, 4th ed. Goleta, California,
American VeterinaryPublications,Inc, 1991,p 411.
12. Dik Kl, Gunsser I: Atlas of Diagnostic Radiology of the Horse. philadelphia, WB
Saunders,1990,p 104.
13. PascoeJR. Pathophysiology of upper aimay obstruction. In White NA, Moore JN
(eds): Equine Surgery. Philadelphia, WB Saunders, 1990, p 213.
14. Honnus CM, Kemper T, Linford RL: What is your diagnosis?J Am Vet Med Assoc
194:1769, 1989.
15. Bllthe LL, Cardinet GH 3rd, Meagher DM, et al: Palatal myositis in horses with
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
epiglottic shortening in two horses. I Am Vet Med Assoc l:g:6i7, 1981.
17. Freeman DE: Dorsal displacement of the soft palate. In \ /hite NA, Moore JN
(eds): Equine Surgery. Philadelphia, WB Saunders, 1990, p 230.
18. Robertson JT: Pharlnx and larlmx. In Beech I (ed): Equine Respiratory Disorders.
Philadelphia,Lea & Febiger,199i, p 331.
19. Cook WR: The auditory tube diverticulum (guttural pouch) in the horse; Its
radiographic examination. J Am Vet Radiol Soc 2:51, 1923.
20. Barber SM: Diseasesof the guttural pouches. In Colahan PT, Mayhew JG, Merritt
AM, Moore JN (eds): Equine Medicine and Surgery, 4th ed. Goleta, California,
American Veterinary Publications, Inc, 1991.
2I. Lingard. DR, Gosser HS, Monfart TN: Acute epistaxis associated with guttural
pouch mycosis in two horses. J Am Vet Med Assoc 164:1038,1974.
22. Bayley WM, Robertson lT: Epistxis caused by foreign body penetration of a
guttural pouch. I Am Vet Med Assoc 180:L232,1982.

23. Freeman DE: Guttural pouches.In Beech J (ed): Equine RespiratoryDisorders.
Philadelphia, Lea & Febiger, 1991
24. Cook WR: The clinical features of guttural pouch mycosis in the horse. Vet Rec
8 3 :3 3 6 ,1 9 6 8 .
25. Freeman DE: Guttural pouch empyema. In White NA, Moore IN (eds); Equine
Surgery.Philadelphia,WB Saunders,1990,p 240.
26, Farrow CS: Pneumomediastinum in the horse: A complication of transtracheal
aspiration.J Am Vet Radiol Soc 17:192,1976.
27. Caron JR Townsend HGG: Tracheal perforation and widespread subcutaneous
emphysemain a horse. Can Vet J 25:339,1984.
28. Fubini SL, Todhunter RJ, Vivrette SL, Hackett RP: Tracheal rupture in two horses.
J Am Vet Med Assoc 187:69,1985.
29. Peek SR De LaHunta A, Hackett RP: Combined esophagealduplication cyst in an
Arabian filly. Equine Vct J 27:475, 1995.
30. FreemanDE: Tracirea.In BeechJ (ed): Equine RespiratoryDisorders.Philadelphia,
Lea & Febiger,1991.
31. Carig CR, GroenendykS, SeawrightAA: l)orsoventralflattening ofthe tracheaof
a horse and its attempted surgical correction: A case report. ] Am Vet Radiol Soc
14:32,1973.
32. Simmons TR, Peterson M, Parker J, et al: Tracheal collapse due to chondrodysplasia
in a miniature horse foal. Equine Pract l0:39, 1988.
33. Dik KJ, GunsserI: Atlas of DiagnosticRadiology of the Horse. Philadelphia,WB
Saunders,1990,p 106.
34. Koch C: Diseasesof the larynx and pharynx of the horse. Comp Contin Educ
Pract Vet 5:S73,1980.
35. Hillidge CJ, SaneckiRK, Theodorakis MC: Thyroid carcinoma in a horse. J Am
Ve t Me d A sso c1 8 1 :7 1 1,1982.
36. Traub-DargatzJL, Ingram JT, StashakTS, et al: Respiratorystridor associated
with
polymyopathy suspected to be hyperkinetic periodic paralysis in four Quarter Horse
foals. J Anr Vet Med Assoc 201:85, 1992.
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-
inch x-ray film (Fig. 36-14 and B). By comparison,four lilms of
this size are neededto image the thorax of an adult horse (Figs.
36-2 through 36-5).
I Normal appearance
A standard radiographic examination of the thorax of an adult
horse comprises four projections, including (1) craniodorsai,(2)
cranioventral,(3) caudodorsal,and (4) caudoventral.Each requires
a different radiographic technique. Cardiovascularassessmentis
optimized by centering the heart on a single 14 X l7-inch film.
Refer to Figures36-2 through 36-5.
Craniodorsal proiection
The dorsal part of the heart, the cranial aorta, and the large
pulmonary arteries and veins are evident in this view. Also seen
are the trachea, the tracheal bifurcation, and the continuing bron-
chi. The lung is visible, but it is difficult to evaluate because of
superimpositionby the heart and vessels.An accurateassessment
of heart size is impossible from this view.
Cranioventral projection
Most of the heart, the aortic origin, the cranial mediastinum,and
the thoracic part of the trachea are visible in this view. The scapulae
The E quineLung 463
37. Naylor J: Equine hlperkalemic periodic paralysis. Can Vet J 35:279,1994.
38. Berry CR: ACVR Film Reading Session; Case 5. Vet Radiol Ultrasound 36:332,
1995.
39. Berry CR: Answers for Film Reading Session; Case 5. Vet Radiol Ultraosund
36:449, 1995.
W Ouestions
1. Radiographically,how can epiglottic dysfunction be evaluated?
2. Which of the following radiographic features characterizephar-
yngitis?
A. Increasedpharyngealopacity
B. Decreasedpharyngealopacity
C. Irregular pharyngealcontours
D. Reducedpharyngealvolume
E. Increasedpharyngealvolume
F. Patchy pharyngeal opacities
G. None of the above
3. What is epiglottiditis,and how might it appearradiographically?
4. What are the two most common causesof laryngeal calcification
in order of likelihood?
5. What is the major limitation to lateral or oblique projectionsin
attemptingto confirm the presenceof unilateralguttural pouch dis-
ease?
Answers begin on page 727.
and one or both humeri usually are visible cranially.The lung is
typically overexposed and difficult to see clearly because of the
high kilovoltage required to penetrate the thick cardiovascular
tissuesand the musculature of the partially superimposedproximal
forelimbs.
Caudodorsal proiection
This projection providesthe largestunobstructedview of the lung.
It is important to recognize that normal interstitial lung opacities
in the horse are particularly outstanding, especiallywhen compared
with dogs and cats. The vascular size and pathways are relatively
constantin this region of the lung, making it the ideal location for
assessingpulmonary circulation. The diaphragm usually appears
flattened, or the thoracic side may be slightly convex.
Caudoventral projection
This view provides visualization of the caudal part of the heart,
the left atrium, and associatedpulmonarv veins. A radiolucent
triangle of lung, bounded by the iaudal vena cavaithe ventral part
of the diaphragm, and the caudalmargin of the heart, is a conve-
nient location for evaluating the lung parenchyma.
Of the four describedprojections,the caudodorsaland caudo-
ventral views are most apt to reveal any pathologic processesln
the lung.
Text continuedon Dage168
4G,4 NECKAND THORAX-EOUIDAE

w/ry
Coudolveno covo

Principol bronchi

'Diophrogm

Figure 36-1- A, Normalfoal thoracicradiograph,right lat-

eralproj ecti on.
B , C ompanon l i nedraw i ng.N otethe rel ati v el y
l argeappearance of the heart,a normalfi ndi ngi n foal s .
 The E quineLung 465

End-on view ol ,/

Figure 36-2. A, Normaladult thoracicradiograph,

ri g h t l a t e r a p r o l e c t i o nd, o r so cr a n iaa lsp e ct.B, Co m -
o a n i o nl i n ed r a w i n o .
A ND T H O R AX -EOU ID A E

Figure 36-3. A, Normaladultthoracicradiograph,right lateralpro-

j ecti on,dorsocauda
aspect.8, C ompani on
l i nedraw i ng .
 The EquineLung 467

illltll,,,rllll
-'llll"llll

'rl,r'li

Figure 3H. 4, Normaladut thoracicradiograph,right ateralprojection,ventrocranial

aspect.8, Companionline drawing.

,: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
' ' . . ' ii, id| t r l g , , : l q

',.'i,,''':ll..l,tlll8ll*
. . , , i. t . , , , t i ; t r , l s r r . 'l l 1 F

.;.::i
'. .: lrr.ll":il$lllr":11&llr'

' Sl
- -4::

:,A;9.;iP|ari9ll$i
-.. :,.,,,:,,,, ::,,,,,iiir, ii6|iii

Figure 36-5. A, Normaladultthoracicradiograph,right lateralprojection,ventrocaudalaspect.8, Companionline drawing.

468 NE CKA ND T H OR AX -EOU ID A E

I Supplementary projections Inspiration-expiration comparison

Spot radiographs and alternate-side
radiography
Optimal imaging is obtained when a lesion or region of interestis
centeredradiographically.Thus, once such a lesionhasbeenlocated
in a standard radiographic series,it is often advisableto obtain a
radiographwith the lesion centeredin the field-of-viewto improve
image clarity. Clarity may be further enhanced by reducing the
distance between the lesion and the film, that is, by obtaining
another radiograph with the opposite side of the patient next to
the cassette,thereby reducing magnification and improving the
sharpnessand detail of the image (Fig.36-6).
Intentional overexposure
By using a more penetrating x-ray beam (increasedkilovoltage
peak [kvp]), it is often possibleto seeadditional detail in certain
types of lesions,such as a cavitatedlung abscess.
radiographs
In patients with suspectedchronic obstructive lung disease,air
trapping may be inferred radiographically on the basis of minimal
or no difference in lung volume in two sequential radiographs, one
on maximal inspiration and the other on maximal expiration. This
technique is especiallyuseful in animals that have otherwise normal
radiographic findings. Obviously, when these sequential examina-
tions are compared, care must be taken to be certain that the
radiographshave been exposedin opposite phasesof the respira-
IOry cycle.
I Diagnostic limitations
The greatestlimitation in adult equine thoracic radiographyis the
inability to view the lung in other than the lateral view. Although
alternate-sideradiographymay be of some help in establishingthe
laterality of peripherallylocated lesions,it in no way supplants a
ventrodorsalproiection.

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

Figure 36-7. A, Cose-uplateral

thoracic Thereis a largey-shaped
radiograph. a r bronchogram
ami dstw i despreadpul monaryconsol i dati on.
B , C ompani on
l i ne
drawing. pneumonia.
Diagnosis:

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

Figure 36-9. Lateral radiograph

thoracic in
in whichthereis a mildincrease
mild,diffuse
Diagnosis:
lungopacity.
overall pneumonia
interstitial

Figure 36-11. Lateralthoracic radiograph.Note the marked increasein

dently.6Abscessesmay occur deep in the lung, superficially, imme-
diately beneath the pleural surface, or in the mediastinum. They
may be singular or multiple' large or small, and sharply or vaguely
marginated. The most characteristic apPearanceof a pulmonary
abscessis that of a baseball-sizedopacity located in the caudal
third of the lung, often dorsally (Fig. 36-1a)' Well-marginated
pulmonary consolidation may mimic abscessation(Fig. 36-15).
Some abscessescommunicate with an adjacent bronchus, allowing
air to enter the abscesscavity, thereby producing a characteristic
gas-fluid interface (Fig. 36-16).
l ung opaci fi cati on
obscuri ngthe caudalheartmargi nand regi onalv as c ul ature.
A l thoughabscesses are suggestedradi ographi caltherel y, w ere nonefoundat
necropsy. D i agnosi s:mi xedi ntersti ti al pneumoni a.
consol i dati ve
Pleuropneumonia
In many horses,bacterial pneumonia spreadsto the lung surface
and into the pleural space.T This is calledpleuropneumonia.8As a
result, Iarge volumes of pleural fluid are often produced; this
fluid makes radiographic evaluation of the lung impossible. \4/here
pleural fluid and consolidation or abscessationare seen together,
and there is no history of trauma, pleuropneumonia is likely.

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

F i g u r c 3 6 - 1 2 . C l ose - u pla te r a lth o r a cc r a d o g r a p ho f

c a u d o d o r s aui n gf i e l d .No teth e d ffu se p u m o n a r yn o d u le s.
D a g n o s i sf:u n g a lp n e u m o na .

:a:,)l:

,,;,ll""ll'

Figure 36-13, Close-uplateralthoracic radiographof the mid-dorsa lung

f ie d i n w h i c h t h e r e i s co n soid a tio no f th e ve n tr a lh a lfo f th e luno.D i aonosi s: Fi gure 36-14. Lateralthoraci cradi ographi n w hi ch there i s a l ung mas s ,
f un q a lo n e u m o n i a . parti al lsuperi
y mposed
on caudalvenacava.D i agnosi s:Lunga bs c es s .
472 NE CKA ND T H O R AX -EOU ID A E
Figure 36-15. Lateralthoracicradiograph.
of c o n s o l i d a t i oi n t h e c e n tr a lu
l n gfie ld .Dia g n o sis:
ou m o n a r vc o n s oi d a t l o n.
Lung rupture and the accumulation of
extrapulmonary air
Rupture of the lung usually producespneumothorax,often associ-
ated with pulmonary contusion. Occasionally, there also may be
hemothorax. Most such iniuries are causedby blunt trauma, but
they may be incurred by a penetratingthoracicwound (Fig. 36-18).
Pulmonary hyperemia, oligemia, and
vascular deficit
Heart disease,whether congenitaior acquired,is the most common
causeof altered pulmonary vasculaturein the horse' In neonates
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.
Thereis a weli-marginated
p n e u m o n iawi
, th extensl ve
with persistent fetal intracardiac communications such as patent
foramen ovale, associated pulmonary hypertension results in a
diminished vasculature. In older foals, isolated intra- or extracar-
diac communications typicaliy produce a pulmonary overcircula-
tion. In complex cardiac anomalies in which right-sided outflow
obstruction exists, blood may shunt from the right to the left
side of the heart, causing a reduction in pulmonary blood flow."
Congestive heart failure is usually associated with a hyperemic
lung, in addition to cardiomegalyand pulmonary edema.Pneumo-
nia may also be associatedwith regional hyperemia, as is true of
most inflammatory conditions. Conversely,the pulmonary vascula-
ture often appears small, with advanced emphysema and other
forms of chronic obstructive lung disease.
Thrombosis, depending on its location and the availability of
collateral circulation, may result in a vascular deficit or "disappear-
ance" of one or more pulmonary vessels,with or without a visible
pulmonary infarct. Pulmonary thromboembolism may also be as-
sociatedwith small nodular opacities, although these are extremely
difficult to differentiate from end-on vascular proiections.'s
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
region volume initially enlarges the pulmonary veins, later resulting in
accumulationof fluid in the interstitium (i.e., perivascularintersti-
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
difficult radiographic determination to make in animals with left
atrial enlargement and pulmonary hyperemia, and especiallydiffi-
cult in horses becauseonly lateral projections are usually available.
The causesof pulmonary edema are broadly divided into those
due to circulatory causes,such as heart failure or fluid overload,
and those that are unrelated to heart disease,in which increased
capillary permeability is the fundamental diseasemechanism. Ex-
amplesof the latter include aspirationof stomachcontents,smoke
inhalation, near-drowning,and strangulation.One way of separat-
ing cardiac from noncardiac pulmonary edema is the rapidity with
which the former may resolve-often in as little as 24 hours with
effective theraov.

Figure 36-17. Close-uplateralthoracicradiographof
c a u d o d o r s al ul n g f i e ld in wh ich th e r e is a n o va l- sh a p e d ,
i l l - d e { i n e du n g r . r a ssa d ja ce n rt o th e d o "sa le d g e o f r h e
d i a p h r a g mD. i a g n o sis: e xe r cise - in d u cepdu lm o n a r yh e m -
onhage.
Noncardiac pulmonary edema has been reported recently in
horses immediately following inhalation anesthesia.Proposed
causesincluded severe alveolar hypoxia related to anesthesiaand
acute upper airway obstruction during recovery.ls
Chronic bronchitis and bronchiectasis
Chronic bronchial diseaseis capableof causingenough structural
alteration in the bronchi and surrounding connectivetissueto be
recognized radiographically.When present, bronchial diseaseis
characterized by an outlining or accentuation of the large and
middle airways, enhancing their radiographic visibility. Seen on
end, the diseasedbronchus resemblesa ring; in profile, the affected
airway appearsas a pair of parallel lines'' (Fig. 36-19).
Bronchiectasis,generallyconsideredto be an end stageof chronic
bronchitis, is characterizedby a pronounced accentuationof the
large and medium-sized airways,at times accompaniedby cylindri-
cal or saccular enlargement of one or more bronchi. Because
bronchiectatic airways often contain fluid, end-on projections of
Figure 36-18. Close-uplateralthoracic radiographof the craniodorsallung field.
The surfaceof collapsedlung (arrow)is seen ventralto a largeaccumulationof pleural
a i r .D i a o n o s i so:n e u mo th o r aaxn d a te le cta sis.
The E quineLung 473
such bronchi or bronchiolesmay appearas lung nodules,or in the
caseof larger airways,as lung masses.
Chronic obstructive lung disease
Chronic obstructivelung diseaseis the most common pulmonary
disorder of mature horsesthroughout most parts of the world. The
majority of these disorders are associatedwith a normal radio-
graph; the minority have abnormal-appearinglungs. In this latter
regard, there are no consistentfindings, although the lung and
airways are usually diffusely affected-often by linear and ring-
shaped opacities,or by very small, poorly defined lung nodules.
Functionaily, especially in the advanced stagesof these disorders,
chronic obstructive lung diseasemay be inferred from the radio-
graphic triad of (1) hyperinflation, (2) hyperlucency,and (3) pul-
monary oligemia, particularly if present on both inspiratory and
expiratory radiographs.Some of thesehorsesalso show a uniform
tracheobronchialdilation (seeFig. 36-19).
474 NE CKA ND T H OR AX -EOU ID A E
Allergic lung disease
The majority of allergiclungs appearnormal radiographically.With
long-standing allergic lung disease,there may be excessive"1ung
markings," which are believed to rePresentthickened small airways,
many of which are obstructedby abnormal secretions.
Lung neoplasia
Primary lung tumors are rare in the horse; granular cell tumors
(myoblastoma)are the most frequently reported. Secondarylung
tumors, or pulmonary metastases,occur occasionally,with one
study reporting adenocarcinomaas the most common, arisingfrom
primary sites in the thyroid, kidney, ovary, and uterus.
-
Radiographically,most primary lung tumors appear as large
solitary lung masses,and the typical pulmonary metastasisis repre-
sentedby widespreadsphericalopacities-usually indistinctly mar-
ginated owing to the effectsof superimposition'toSome metastatic
lisions, however,appearas ill-defined nodules,and othersas patchy
lrrr .i t,t:
':::a..:::a:'
:), .
rrrllrtr,,,tlttl
::,11:,,,;;;i11"
,rr:lll..l:il
Figure 36-19- Close-uplateralthoracicradiographof the
caudodorsal l ungfi el d.The l argeand medi umbronc htappear
thi ckenedand enl argedas evi dencedby numerousl i ne and
rl ngopaci ti es. emphysemaand bro nc hi ec tas i s .
D i agnosi s:
consolidation.Unlike in pet animais,widespreadsphericalopacities
in horses are more likely to represent abscessationthan cancer.
Mesotheliomaaffectsthe pleural surfacesof both the lung and
the thoracic cavity and characteristically produces a large volume
of pleural fluid, which is usually microscopicallydiagnostic.Radio-
graphically (or sonographically),mesothelioma,and in particular
the pleural fluid that it causes,cannot be distinguishedfrom non-
neoplasticpleuritis.2'
Diaphragmatic hernia
Most diaphragmatichernias are the result of injury. Radiographic
observationsare predicatedon the following factors: (1) the size
and location of the diaphragmatictear, (2) the extent and location
of abdominal contentswithin the thorax, (3) the amount of resul-
tant lung compression,and (4) the volume of fluid produced and
accumulated within the thoracic cavity. Cylindrical intrathoracic
transparenciesstrongly suggestherniated intestine (Fig. 36-20). A
barium study also definesa herniated stomachor bowel.
Figure 36-2O. Close-uplateralthoracicradiographof the cau-
dodorsaL l ung fi ed. S everalai r and fl ui dJi l l edb ow el s egments ,
w hi chare hi ghl i ghted
by a l argevol umeof surro undi ng pl euralai r
(arrows),can be seen. Ventrallythere is near total opacification,
the resul tof superi mposed i ntestl ne, , pl eural
l i ver,atel ec tas i sand
hemorrhage. di aphragmatlherni
D i agnosi s: c a.
 The PleuralSpace 47|5

References
1. Kangstrom LE: The radiological diagnosis of equine pneumonia. Vet Radiol
9:8 0 ,1 9 6 8 .
2. Raphel CF, tseech lB: Pleuritis secondary to pneumonia or lung abscessationin
90 horses.J Am Vet Med Assoc 181:808,1982.
3. Mair TS, Lane JG: Pneumonia, lung abscessesand pleuritis in adult horses: A
review of 51 cases.Equine Vet J 2l:175, 1989.
19. Farrow CS: Radiographic aspects of inflammatory lung diseasein the horse. Vet
Radiol 22:107,1989.
20. Dik KL Gunser I: Atlas of diagnostic radiology of the horse. part 3: Diseasesof
the head, neck, and thorax. Philadelphia, WB Saunders, 1990,pp 160, 162, 164.
21. Mair TS, Hillyer MH, Brown PJ: Mesothelioma of the pleural cavity in a horse:
Diagnostic features. Equine Vet Educ 4:59, 1992.

4. Buergelt CD: Interstitial pneumonia in the horse: A fledgling morphological entity

with mysterious causes.Equine Yet J 27:4, 1995.
5. Ruoff WW: Fungal pneumonia in horses. Proc Am Assoc Equine Pract 423, 1988.
6. Lavoie Jq Fiset L, Laverty S: Review of 40 casesof lung abscessesin foals and
adult horses. Equine Vet I 261348,1994.
ffi Ouestions
l. \Arhat is pleuropneumonia? How is it postulated to develop?Ii
it worse than pneumonia without a pleural component? How
difficult is it to diagnose radiographically?

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
the head, neck, and thorax. Philadelphia,WB Saunders,1990,p 156.
16. Morgan PW, Goodman LR: Pulmonary edcma and adult respiratory distress
syndrome.Radiol Clin North Am 29:943,1991.
17. Staub NC, Nagara H, Pearce ML: Pulmonary edema in dogs, especiallythe
sequenceoffluid accumulationin the lungs. J Appl Physiol22:227,1967.
18. Ball MA, liim CM: Post anesthesiapulmonary edema in 2 horses. Equine Vet
8 :1 3 ,1 9 9 6 .
8. In which portion ofthe lung are radiographicchangesassociated
with equine bacterialpneumonia most likely to be seen?
9. Even though it is not possible to obtain ventrodorsal radio-
graphs of the equine thorax, how might one determine if a lung
massis in the right or left lung?
Answers begin on page 727.

CHA P T E R

37
The Pleural Space
. RussellL. Tircker . Ronald D. Sande

I Anatomy
Pleural anatomy should be taken into consideration when the
equine thorax is evaiuated.Horses have minimal external lung lobe
separationand lack prominent interlobar fissures.The mediasti-
num is partially fenestrated.The parietal pleura is reflected along
three major boundaries,which serve as important landmarks in
diagnostic imaging.t At the sternal line of reflection, the costal
pleura reflects dorsaliy to become the visceral pleura of the ventral
mediastinum. At the vertebral line of reflection, the costal pleura
turns ventrally to form the dorsal mediastinal pleura. Perhapsthe
most important pleural reflection in diagnostic imaging is the
diaphragmatic reflection, at which the parietal pleura of the costal
surface extends to the surface of the diaphragm and forms the
costodiaphragmaticrecess.This line is the demarcation between
the thorax and the abdomen. The anatomic limits of the costo-
diaphragmatic recessmay be estimated on the surface of the horse
by piacement of a line connectingthe following points: the lTth
intercostalspaceat the level ofthe tuber coxae;the 15th intercostal
spaceat the level of the tuber ischii; the l3th intercostalspaceat
the dorsoventralmidpoint; the 11th intercostalspaceat the level
of the point of the shoulder; and a gradually descendingline
to the point of the elbow. Radiographically, this line is located
a?proximatelyat the level of the costochondraljunctions caudalto
the ninth rib, where it courses caudally and dorsally at a gradually
increasing distance from the sternal ends of the ribs to the level of
the midshaft of the last rib. It then reflects slightly cranially and
dorsally to terminate at the vertebral end of ihe last intercostal
space.
Radiographic examination of the thorax for the purpose of
476 NE CKA ND T H OR AX -EOU ID A E
evaluating the pleural spaceis performed with the same technique
usedto evaluateother thoracic structures'Horizontal-beamprojec-
tions are made with the patient standing.Three or four projections
of each side may be required to properly evaluatethe entire pieural
spacein larger horses.Whenever possible,a grid technique, prefer-
ably with a iuspended Bucky grid system,should be used to reduce
scatter radiation. If a grid is not available, leaving an air gap
between the patient and the cassettecan reduce the effect of scatter
radiation; however, this technique creates increased parallax and
magnification.'
Survey examination for diseasesof the pleural space should
include at least one right and one left lateral projection of the
caudal ventral portion of the thorax. Right and left lateral projec-
tions permit evaluation of each side of the thorax. Substantial
diseaseis magnified but can be missed if the diseaseis unilateral
or is largely asymmetrical and the affected side is positioned away
from the cassette.The need for additional projections may be
determined based on the preliminary findings and the severity of
the disease.
I Ultrasonography
Ultrasonography may be used for primary examination of the
thorax or to augment radiographic findings. Portable ultrasound
machines often provide the initial method of imaging the pleural
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
with ultrasonography.'Ultrasonography is alsoextremelyuseful for
locating and determining the boundariesof fluid-filled spaces.This
provides an inexpensivemethod by which the responseof pleural
diseaseto treatment can be monitored. Ultrasonographicexamina-
tion is used to study tissue texture or fluid composition and may
provide an etiologic diagnosisin horses with pleuropneumonia''
Ultrasonography,which can be used to guide catheterplacement
for targetedthoracentesis, ensuresproductiveyields.tThe literature
should be consulted for a more complete understandingof this
valuable imaging modality.n n
I Diseasesof the pleura
I and pleural space
Pleural effusion
Accumulation of fluid within the pleural spaceis often a nonspe-
cific finding. Differentiation of transudate, exudate' or blood is
impossible without a thoracentesis.Many folds and pockets exist
within the mediastinum and pleural cavities. Horses are usually in
a standingposition and, as expected,accumulationof fluid is most
often dependent. The earliest radiographic sign of fluid in the
pleural space is loss of detail in the ventral aspect of the thora-'r
caudal to the heart (Fig. 37-1). The area cranial to the heart is
more difficult to evaluate. Loss of vascular detail within any pafi
of the lung nearestthe ventral margin of the thorax is an indication
of pleural effusion. The volume of fluid required for radiographic
detection varies with the size of the patient and the quality of the
study. Perhaps no less than 1 or 2 L in any compartment can be
detected in a 450-kg patient. Greater volumes of fluid result in loss
of detail, which progressesdorsally in the thorax, causing silhouet-
ting of the fluid with the borders of the diaphragm and the heart.
Deipite the opinion that fluid moves freely between the right and
left pleural spaces,it is common to find compartmentalizationof
the fluid or unilateral fluid; the latter is most often associated
with inflammatory conditions and is best studied by the use of
ultrasonography. Fat adjacent to the heart in the mediastinum
causesaccentuation of the costal border of the lungs in the caudal
ll!llr
s
,,,.lgl
{.*
g-f
;jiii.lr.,,
.l
:
triii,i,i:,,r,:
jn d* jt
Sf*
6,,'iiir
Figure 37-1. Left-right of an equinethoraxwith a small
lateralradiograph
Theventralmarginof the lungis visl'le (anows).
pleuraleffusion. Noticethe
silhouettesignof the ventral
heartanddaphragm andlossof detailof the
peripheralrightmiddlepulmonary vasculature.
thorax. This normal finding is often misinterpretedas the accumu-
lation of fluid.
A common error in radiographic interpretation is made when
one expects to always find a fluid line with pleural effusion. The
characteristic fluid line (horizontal fluid-air interface) is createdby
the interface of the pleural effusion ventrally and the free gas
dorsally.Becauseof the capillarity and surfacetension, a straight
(horizontal) fluid line is not presentunlessthere is also free gas in
the pleural space.In the absenceof free gas within the pleural
space,a straight fluid line will not be seen even though pleural
effusion may be present.
The pathogenesisof pleural effusion is complex, and the causes
are many.3''0Pleural effusion may be primary or secondaryand
may be associatedwith coexistingdisease.Reportedcausesinclude
r-'aprimary neoplasia,lsabdominal neoplasia,'u
thoracic metastasis,r
inhaled foreign bodies,'t''* and primaryre-22and systemic infec-
tion'z3;it may also occur secondary to pneumonia, pulmonary
abscess, trauma,2aand pulmonary infarction.'?s Our experiencealso
includes pleural effusion associatedwith esophagealperforation
and descendingcellulitis and as a sequelto respiratory infection
compoundedby stress.
Pleural effusion,regardlessofcause, is usually detectedon physi-
cal examination, including auscultation and percussion. Radio-
graphic examination may be used to substantiatethe clinical diag-
nosis. Radiographic signs vary according to the volume of fluid
present; howeveq negative findings do not preclude the presence
of significant fluid."' Small volumes of fluid result in increased
opacity and loss of detail in the ventrocaudal thorax. Increased
volumes of fluid result in progressivesilhouettingof the border of
the diaphragm, the heart, and the vena cava (Fig. 37-2). These
signs are compounded by concomitant collapse of the lungs with
increasedpulmonary opacity and loss of detail due to reduction of
air from the pulmonary parenchyma.
The prognosis and treatment of pleural effusion are not often
determined or altered by the radiographic findings. Radiographic
evidence of fluid in the pleural space or mediastinum does not
provide definitive information as to the cause. To determine the
etiology of pleural effusion, thoracentesisis necessary.
Ultrasonography is very useful for locating and characterizing
pleural effusions. Its echogenic characteristicscan reveal details of
 The P l eur alSpace 477

Figure 37-2. Left-rightlateralradiographof the dorso-

c a u d a tl h o r a xo f a n ad u lt h o r sewith se p ticp le u r itis.No -
ticethe increaseo d pa citva n d lo sso f d e ta ilin th e ve n tr a l
t h o r a x .T h e o p a c i t yfr o m th e flu id is so g r e a t th a t th e
dorsal ljmit of the fluid (arrows)may be confusedwith
t h e e d g e o f t h e x - r ayb e a m . De ta ilo f th e h e a r t,ca u d a l
v e n a c a v a ,d i a p h r a gma, n d m u ch o f th e lu n g h a s b e e n
obscured.The dorsalmarginof the aortais visible/arow-
heads).

the fluid's cellularity and inflammatory nature. The amount and
Ievel of the fluid can be accurately visualized and followed over
time. In addition, the condition of the surface and subpleural tissue
of the adjacent lung can be evaluated (Fig. 37-3). The detection of
free gas echoes associated with anaerobic bacterial infection, exten-
sive fibrinous tags, or areas of loculation within the pleural fluid
is associated with a poor prognosis, requiring a more extensive
therapeutic regimen.3 Ultrasonography is invaluable for performing
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
fluid. Ultrasonographic examination may be difficult or impossible
when a large volume of free air is present in the pleural space.a
Pleuritis
Radiographic signs of acute or subacute pleuritis are often not
differentiated from those of effusion. The presence of fibrin re-
mains undetectedunlessit causesrestriction of the lung margins.
Becausethe equine lung is not divided by deep interlobar fissures,
the scalloped borders characteristic of restrictive pleuritis in other
species are not typically seen. Accumulation oi fibrin may be
detected when pleural adhesions and fibrin sheets form and the
pleural fluid regresses.The fibrin tags tend to orient vertically
within the pleural spaceor are at least more easily identified when
their axesare orthogonal to the vesselsand airways within the lung
(Fig.37-4).
Severechronic fibrinous pleuritis mav become compartmental-
ized, resulting in cavitary pieural disease,which is difhcult if not
impossible to distinguish from cavitary lung disease.Compartmen-
talization of pleural fluid often results in confusing imiges (Fig.
37-5). The inability to perform a dorsoventral or ventrodorsal
projection of the equine thorax often limits the clinician to specula-
tion regardingthe location of many lesions.Ultrasonography
prove helpful for identifying cavitary pleural disease. -ry
Ultrasonographicexamination can allow for detection of subtle
pleural thickening and inflammatory changes in the early phases
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
irregular in the early phasesof the disease.With progression,Iarger
subpleuralconsolidationsand abscessation of peripherallung tissue
may become evident with ultrasonography(Fig' 37-6).
Pleural and extrapleural masses
In the absence of excessivefree fluid, a pleural mass may be
visualized radiographically. The location of the mass may be deter-
mined by the use ofopposing projections(Fig.37-7). Radiography
is likely to be informative when the lung surface is normal and
changesoccur more deeply within lung tissue or are confined to
the mediastinum."
Tissue massesextending from the pleural surface or in contact
with the costal pleura may be best examined with the use of
ultrasonography.
Pneumothorax
Pneumothoraxhas multiple causes,although the sourcesof air are
limited to the lung, esophagus, and external body surface. The
Figure 374. Right-left lateraradiograph
of an equinethorax
with chronicpleuritis. signof the heart,the
Thereis a silhouette
ventraldiaphragm,and the caudalvenacava.Thickened pleura
and adhesions may be identifiedas opaquelineswith vertical
orientation
laffows.)
finding of large volumes of gas in the pleural space as a result of
gas-producing bacteria is very rare. However, it is common to find
entrappedgas within an abscess(seeFig. 37-5).
The hallmark radiographicsign of pneumothoraxis clearvisual-
ization of the margins of the lungs. Air in the pleural spacerises
dorsally and compartmentalizes according to the availabie space.
In the standing horse, free air quickly moves dorsally, adjacent to
the spine. The mass of pulmonary and cardiactissuein the horse
results in dependent displacementof tissue in relation to air. Sharp
visualizationof the dorsal lung margins is a reliable sign of air in
the pleural space(Fig. 37-8). Right and left lateral projectionsmay
be necessaryfor accurateidentification of the pulmonary margins
and for determination of the location of the pneumothorax. The
detection of pneumothorax does not enable identification of the
precise location of air within the thorax, nor does it define the
cause. The use of ultrasonography to detect pneumothorax is
difficult becausethe free air in the dorsal thorax and that in the
aeratedventral lung appear sonographically similar.'
Pneumomediastinumcan result whenever a significant volume
of free gas is introduced into, or is produced within, the mediasti-
Figure 37-5. Left-rightlateral thoracic radiographof
the horse in Figure37-2 made 7 weeks later.Note the
cavitaryspaces in the lung parenchyma(arrows).Fluid
and alr, as demonstratedby the interface(arrowheads),
are compartmental i zedi n the pl eural spac e. S i mi l ar
changespersisted5 months later.
 The P l euralSpace 479

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.

Figure 37-8. Right-eft lateralradiographof the thorax of a horse with

pne u m o t h o r a xR. a d i o g r a p hsig
ic n s n clu d evisib lelu n g b o r d e r( sol i darrow s),
dorsal marginof the esophagus(openarrows),and increaseddetail of the
marginsof the aorta (arrowheads).
48O NE CKA ND TH O R AX -EOU ID A E
num. This can occur secondary to cervical, tracheal, or esophageal
puncture, or as the result of anaerobicmediastinalinfection. Pneu-
momediastinum that developsafter transtrachealaspiration is com-
mon. In contrast to the radiographic features of pneumothorax,
air within the mediastinum outlines the aorta and does not displace
the lung margins.
References
1. Getty R: Sisson and Grossman'sThe Anatomy of the Domestic Animals. Philadel-
phia, WB Saunders, 1.975,p 514.
2. Butler IA, Colles CM, Dyson SL et al: Clinical Radiology of the Horse. Oxford,
Blackwell Science, 1993, p 423.
3. Ainsworth DM, Biller DS: Respiratory system. In Reed SM, Bayly WM (eds):
Equine Internal Medicine. Philadelphia, WB Saunders, 1998.
4. Reimer JM, Reef VB, Spenser PA: Ultrasonography as a diagnostic aid in horses
with anaerobic bacterial pleuropneumonia and/or pulmonary abscessations:27 cases
(1984-1986).l Am Vet Med Assoc 194:278,1989.
5. Reimer JM: Diagnostic ultrasonography of the equine thorax. Compend Contin
Ed u c P ra c V e t 1 1 :1 1 1 0 ,1 9 90.
6. Rantanen NW: Ultrasound aPpearance of normal lung borders and adjacent
viscerain the horse.Vet Radiol 22:217,1981.
7. Rantanen NW, Ewing RL: Principles of ultrasound application in animals Vet
R a d i o l 2 2 :1 9 6 ,1 9 8 1 .
8. Rantanen NW Gage L, Paradis MR: Ultrasonography as a diagnostic aid in pleural
effusion ofhorses. Vet Radiol 22:211,1981.
9. RantanenNW: Diseasesofthe thorax. Vet Clin North Am Equine Pract 2:49, 1986.
10. Smith BP: Pleuritis and pleural effusion in the horse: A study of 37 cases.I Am
Vet Med Assoc 170:208,1977.
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.
12. Morris DD, Acland HM, Hodge TG: Pleural effusion secondary to metastasis of
an ovarian adenocarcinoma in a horse. i Am Vet Med Assoc 187:272' 1985.
13. RossierY, SweeneyCR, Heyer G, et al: Pleuroscopicdiagnosisof disseminated
hemangiosarcomain a horse. J Am Vet Med Assoc 196:1639,1990.
14. Mueller PO, Morris DD, Carmichael KR et al: Antemortem diagnosis of cholangio-
cellular carcinoma in a horse. I Am Vet Med Assoc 201:899, 1992.
15. Mair TS, Lane JG, Lucke VM: Clinicopathological features of lymphosarcoma
involving the thoracic cavity in the horse. Equine Vet J 17:428, 1985.
16. Harvey KA, Morris DD, Saik JE, et al: Omental fibrosarcoma in a horse. ] Am Vet
Med Assoc l9l:335, 1987.
17. Hultgren BD, Pearson EG, Lassen ED, et al: Pleuritis and pneumonia attributed
to a conifer twig in a bronchus of a horse. J Am Vet Med Assoc 189:797, 1986.
18. O'Brien JK: Septic pleuritis associatedwith an inhaled foreign body in a pony. Vet
R e c l l9 :2 7 4 ,1 9 8 6 .
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-
pneumonia. J Am Vet Med Assoc 187:721,1985.
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.
22. Hoffman AM, Baird JD, Kloeze HJ, et al: Mycoplasmafelis pleurtis in two show-
jumper horses. Cornell Vet 82:155, 1992.
23. Mair TS, Lane JG: Pneumonia, lung abscess,and pleuritis in adult horses: A
review of 5l cases.Equine Yet I 21:175, 1989.
24. Collins MB, Hodgson DR, Hutchins DR: Pleural effusion associatedwith acute
and chronic pleuropneumonia and pleuritis secondary to thoracic wounds in horses:
43 cases(1982-1992). I Am Vet Med Assoc 205:1753, 1994.
25. Carr EA, Carlson GR Wilson WD, et al: Acute hemorrhagic pulmonary infarction
and necrotizing pneumonia in horses: 21 cases (1967 1993). J Am Vet Med Assoc
210:1774, 1997.
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
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
cases(1984 1985). I Am Vet Med Assoc 198:2112, 1991.
w Ouestions
t. The pleural cavity of the horse:
A. Is composedof two potentiai spaces,eachlined by visceral,
parietal, diaphragmatic, and costal pleura, separatedby a
partially fenestratedmediastinum.
B. Contains suffrcient pleural fluid to cause blunting of the
costophrenicangleson radiographicimages.
C. May be located by finding intercostal spacesNumbers 5,
11, and 17 at the level ofthe shoulder,the greatertrochan-
ter, and the tuber coxae,respectively.
D. Is composed of two distinctly separate spaces,having no
communication,that confine a diseaseto one side.
2, Radiographicexaminationof the thorax of the horsefor evalu-
ation of the pleural space:
A. Should include ventrodorsalor dorsoventralprojectionsin
all horseswith thoracic disease.
B. Should not require a grid when high-kVp and moderate-
mAs techniquesare used with high-speedscreen-filmcom-
binations.
C. May require three or four projections in both left and right
lateral,horizontal-bean-r
configurations.
D. Is suitably performed by survey radiography of the caudal
ventral pleural space,where all fluid accumulates.
3. In this left lateral radiograph of the dorsal,caudal thorax of a
7-year-old Quarter horse gelding with respiratory difficulty after
being used as a rodeo horse (Fig. 37-9), what are the significant
findings and what is the radiographicdiagnosis?
4. Radiographicsignsof pleural diseasein the horse:
A. Are first seenas loss of detail in the ventral thorax, craniai
to the heart.
B. Result in loss of detail and obscurity of the aorta, dia-
phragm,and cardiacmargins.
C. Result in a fluid line, indicating the fluid level in the thorax,
on horizontal-beamlateral projections.
D. May require a fluid or air volume in excessof 2 L for
detectionby radiographyof the thorax.
5. Pneumothorax in the horse is usually recognizedby the follow-
rng
A. Elevation of the heart and lung margins from the sternum
B. Clear definition of cardiacmargins
C. Clear definition of the diaphragmaticcrura
D. Clear definition of the dorsal lung margins and aorta
6. In this right lateral projection of the cranial dorsal thorax of a
3-year-old Thoroughbred filly with respiratory distress,elevated
temperature is noted following transport between racetracks (Fig.
37-10). What are the significantfindings and radiographicassess-
ment?
7. Pleural effusion in the horse:
A. Results in retraction of lung margins and scalloped lung
borders on radiographicimages.
B. Results in progressive obscurity of margins of the heart,
diaphragm, and vena cavaon radiographicimages.
C. Is characterizedby cavitary changesand fluid-air interfaces
on radiographicimages.
D. Does not occur as a primary diseaseand is often associated
with radiographic signs of coexisting disease.
8. Which of the following statementsregarding the use of ultraso-
nography in the detection and evaluation ofpleural diseaseis false?
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
oleural effusions.
B. illtrasonography can yield information about the pleural
lining and pericardium.
C. Ultrisonography is useful for evaluation of the lung surface
when a lirge volume of free air is present within the
pleural space.
D. Ultrasonographyis helpful for detectingthe irregular sur-
face of the normally smooth visceralpleura of the lung in
the early phasesof pleuritis and pleuropneumonia'
9. Diagnostic radiology of the equine thorax, for the study of
pleural disease,is better than ultrasonography:
A. When the diseaseis in the mediastinum or occurs deep to
lung tissue.
B. When lesions extend from lung margins into the lung
parenchyma.
C. For differentiation of causes of pleural and mediastinal
masses.
D. For detectionof fibrinous, restrictivepleuritis.
10. In this left lateral radiograph of the thorax of a l2-year-old
Thoroughbred mare being treated for chronic pleuritis (Fig. 37-
11), what are the significantfindings and radiographicassessment?
Answers begin on page 727,
 :!,.,.,.,,.
rrlllrr...rr 'iillt ili:lr:rlilll:'rltl'
:rllttllil:r),.. 9],,r:llli:1,,,1
1i!llt,
a,:,-::::

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
At the completion of this chapter,the readershould be able to:
1. Identift each abdominal zone and know which organs are
within eachzone.
2. Describenormal radiographicsignsfor various abdominal or-
gans.
3. Describe the protocol for making a survey radiograph of a
small animal abdomen.
4. Follow or develop an interpretation paradigm for the small
animal abdomen.
5. Understand the indications for the use of ultrasound, CT,
MRI, and nuclear scintigraphy when evaluating the small animal
abdomen.
to the diaphragm and cranial to the stomach (lateral and ventro-
dorsal zones 1 and 2). The cranial margin of the liver follows the
contours of the diaphragm ("dome" shaped).The caudal margin
is sharply marginated and may be difficult to visualize on the VD
view. There is silhouetting between the lobes of the liver, the liver
and the diaphragm, and sometimesthe liver and the stomach,If
the patient is exceptionally fat, individual liver lobes may be identi-
fied. The liver of both the doe and the cat is divided into four
-quadrate.
lobes: left, right, caudate,and The left and right lobes
are further divided into medial and lateral sublobes.
Normal liver size is empirical; therefore, both views must be
used to make a determination.All indicators neededto assess liver
size may not be present;however,the observermust still decide if

I Anatomy Table 38-7. Region 1

The grossanatomy and radiographicanatomy of the abdomen are Lateral
not exactly the same. For example, there are structures present Liver
that, when normal, are not identified on the radiograph (e.g., R i g h t l a t e r a ll o b e
uterus). It is important to considertheseorgans even though they C a u d a t el o b e
Spleen
may not be visualized becauseif an abnormality is revealed, they
Head
may become enlarged and causea mass effect, or they may develop Stomach
altered opacity (e.g., adrenal gland mineralization) and become F un d u s
visible. The ability to identifu structuresin the abdomen requires Body
the presence of fat, which serves as a contrasting opacity within Bight adrenal gland
the abdomen. Possibly left
When one is reviewing the anatomy of the abdomen, it is helpful Rightkidney
to think about the relationships of organs to each other rather than Possiblycranial part of left
just individual structures. This is especialiy useful when one is Pancreas
Mesenteric lymph node
reviewing mass effect. To better understand the relationships of
organs to each other, one may view the abdomen as being divided Ventrodorsal
into zones-five zones on the lateral view and four zones on the Liver
Rightlobes
ventrodorsal (VD) view (Figs. 3B-l through 3B-5; Tables 3B-1
Gallbladder
through 38-5). Stomach
The use of radiographic signs is helpful in evaluation of abdomi- Pylorus
nal organs. The radiographic anatomy of selectedstructures is P r o x i m a ld u o d e n u m
reviewed in the subsequentsections of this chapter. Pancreas
Rightkidney
Liver Right adrenal gland
Mesenteric lymph node
The liver (seeFigs.38-1 and 38-2) is the largestgland in the body.
It is of soft-tissueopacity and lies in the cranial abdomen, caudal Structures listed in italics are not normallv visuatized.

483
484 A N IMA L S
A B DO M E N-C OMP AN IO N

Table 38-2. Region 2 Table 384. Region 4

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

Structureslisted in italicsare not normallYvisualized. Gallbladder (seeFigs.38-1 and38-2)

The gallbladder is associatedwith the right liver lobes in the dog
and the cat. Being of soft-tissue opacity, the gallbladder is not
the liver is of normal size,is too small, or is too large.The position normally visualized becauseit silhouettes with the liver. The gall-
of the stomach during radiographic examination aids in the deter- bladder may be visualized if abnormal. The following changesmay
mination of liver size.When liver size is assessed, the conformation be seen:mineral opacities (gall stones),gas opacity (gas-forming
of the patient should alwaysbe considered. organism), or metallic opacity due to a positive contrast medium
(secondaryroute of excretion).
Normal liver
Lateral view. The axis of the stomach is parallel to the ribs. Spleen
The caudal margin of the iiver is enclosed within the rib cage or
is very closeto the costalmargin. The size range of the normal spleen (see Figs. 38-1, 38-2, and
38-3) is extremely variable. The spleen in the dog is normally
Hepatomegaly-generalized larger than that in the cat. Many drugs, such as barbiturates, cause
Lateral view.The axis of the stomach (specifically'the pylorus) generalized splenic enlargement. The proximal extremity of the
is in a more caudodorsallocation. The liver margins are rounded. spleen (i.e., the head of the spleen) is connected to the gastric
The liver extends caudal to the costal margin. fundus by the gastrosplenic ligament. The proximal extremity of
Ventrodorsal view. There is an empirical increase in the liver the spleen is located in the left dorsal aspect of the abdomen
mass.The stomach is more caudally displaced and the pylorus may (lateral zone l/ventrodorsal zone 2). The distal extremity of the
be displaced medially. spleen (the tail of the spleen) is located in the ventral abdomen,
but its exact position is highiy variable and it may be on either the
Microhepatia-generalized left side or the right side of midline.
Lateral view, The axis of the stomach (specifically,the pylorus) In radiographs,the x-ray beam strikes portions of the spleen
is in a more cranial location and is more perpendicularwith the end on, resulting in triangular soft-tissue opacities. One must
ribs. There is an overall decreasein liver mass. remember that the spleenis much larger than such triangular opac-
Ventrodorsal view, There is an overall decreasein liver mass. ities.
The stomach is more cranially displaced and the pylorus may be
displaced medially. Abdominal lymph nodes
Abdominal lymph nodes are not normally visualized. They may be
seen if there is an increase in size or, rareiy, a change in opacity.
Table 38-3. Region 3 Ultrasound is an excellentmodality by which to evaluateabdominal
Lateral lymph nodes in small animals.
Spleen Three groups of lymph nodes are of radiographic interest:
Body Medial iliac lymph nodes. These are sometimes cailed
Tail sublumbar lymph nodes. They are in the retroperitoneal space
Pancreas ventral to L6 on the laterai view in zone 4.
Sm all int es t ine Mesenteric lymph nodes. These are within the peritoneal
Large intestine spacein zone 3 on both views.
Left kidney
lnguinal lymph nodes. These are found in the ventral flank
Left ovary
Uterus outside of the abdominal cavitv.
Ventrodorsal
Stomach
Pancreas Table 38-5. Region 5
Sm all int es t ine
Large intestine Lateral
Left kidney Uterus
Right and left ovaries U ri narybl adder
Uterus Ureters
Cranial horns Prostate 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

Liver& kidney liver & kidney

Stomach Stomach,
pancreas& duodenum

Figure 38-1. Lateraland ventrodorsalschematicrepresenrarion

of z o n e 1 r n a d o g . D, d u o d e n u m ;G, g a llb la d d e rL;, live r ; pa,
pa n c r e a sP
; y , p y l o r u s ;RA, r ig h t a d r e n a lg la n d ;RK, r ig h t kidney;
5, S p t e e n .

liver & kidney pancreas

Stomach, & duodenum

liver & stomach

Figure 38-2. Lateraiand ventrodorsalschematicrepresentationof

zone2 i n a dog.D , duodenum,GB ,gal l bl adder;
L, l i ve r;pa, panc reas ;
P y,py/orus;S , spl een;S t, stomach.
4A6 AN IM AL S
A B DO M E N -C OMP AN IO N

$lomach& Smallintestines & $mallintestines

Stomach

Spleen& L KidneY
Stomach, Kidneys

Figure 38-3. Lateraland ventrodorsalschematicrepresentation

of zone3 i n a dog. K , ki dney;S , spl een;S t, stomac h;U , ureter'

Colon

Golon

Figute 3g4. Lateraland ventrodorsalschematicrepresentationo{

z o i e 4 i n a d o g .C , c o lo n ;K, kr d n e y;Pr ,p r o sta teg la n d ;St, stomach;
U B . u r i n a r vb l a d d e r .
 l nterpretati on
Figure 38-5. Latera schematicrepresentationof zone 5 in a dog
( , k i d n e y ,P ,o r o s ra teg la n d ;U, J.e te r ;UB. u r n a r yb la d d e r .
Adrenal glands
Normal adrenalglands(seeFigs.3B-3 and 3B-4) are not visualized
radiographically. The adrenal glands are located in the retroperito-
neal space,craniomedialto the pole of each kidney (lateral zones
1 and 3; ventrodorsalzones 1 and Z). Mineralized adrenal glands
may be seen in the cat as a normal variant. Ultrasound (and
computed tomography if the adrenal glands are known to be
increasedin size) is a good modality for evaluating the adrenal
glands.
Pancreas
The normal pancreas(seeFig. 38-1) is not visualizedradiographi-
cally. The right limb of the pancreas lies adjacent and caudal to
the caudalmargin of the stomach.The left limb of the pancreaslies
medial and adjacent to the descendingduodenum. Radiographic
identificationof pancreaticdiseaseis difficult. Ultrasound is a more
useful imaging modality for assessing the pancreas.
Kidneys
The kidneys (see Figs. 38-1, 38-3, 38-4, and 38-5) are of soft-
tissue opacity and are located in the retroperitoneal space. The
cranial pole of the right kidney is often difficult to visualize because
it is embedded in the renal fossa of the caudate lobe of the liver
and thus silhouetteswith the liver. The left kidney is caudal to the
right kidney, and its location is more variable. In the dog, normal
kidney sizeis 2.5 to 3.5 times the length of L2 (using the ventrodor-
sal view); in the cat, the normal kidney sizeis 2.4 to 3.0 times the
length of L2 (using the ventrodorsalview).
Ureter
The ureters (seeFigs. 38-3, 38-4, and 38-5) lie in the retroperito-
neal spaceand are not normally visualized on survey radiographs.
If visualized following intravenous contrast medium administra-
tion, they should be no larger than 2 to 3 mm.
Urethra
The male urethra comprises three parts: prostatic (narrowest part),
membranous, and penile. The prostatic urethra is confined to the
prostate gland, the membranous urethra extends from the prostate
to the os penis, and the peniie urethra is dorsai to the os penis.
The penile urethra is considerably shorter in the cat than in the
dog. In females,the urethra is shorter and wider than in males.
P aradi gms
for the A bdomen-C ani nea nd Feline 4O 7
Urinary bladder
The size of the urinary bladder (see Figs. 38-4 and 38-5) is
highly variable. If empty, it may not be visible. In dogs that are
housebroken,the bladder may be huge.The bladder may be located
either to the left or to the right of midline, or it may be centered
on the midline, in the ventrodorsal view.
Prostate gland
The diameter of the normal prostate (see Figs. 38-4 and 38*5)
should be no greater than two thirds the width of the pelvic
inlet on the ventrodorsal view. The normal Drostate is not visible
radiographically in the cat, and prosratic diseasein the cat is
very rare.
Uterus
The normal uterus is not visible radiographically.If the uterus can
be visualized, it is abnormally large or gravid. The uterine stump
is located between the bladder and the colon. If the uterus is
gravid, fetal skeletonsbecome visible at approximately day 45.
Ovaries
The ovaries, which lie in the retroperitoneal space caudal to the
kidneys, are not normally identified on survey radiographs. Abnor-
malities of the ovariesare not common, but they should be consid-
ered on the differential list for dorsal to midabdominal massesin
intact females.
Testicles
The testiclesare not typically evaluated using conventional radiog-
raphy. Consider a retained testicle as the cause of an abdominal
mass in a cryptorchid male dog. Feminization may be associated
with malignant transformation of retained testicles; radiographic
signs may include nipple enlargement (gynecomastia)and prostatic
enlargement.
Stomach
The stomach (see Figs. 38-1 to 38-4) lies immediately caudal to
the liver and cranial to the transverse colon. The axis of the
stomach should be parallel to the ribs on the lateral view The
pylorus of the dog is generallyto the right of midline, and the
pylorus of the cat is generally on midline or slightly to the left of
midline. The size of the stomach is extremeiy variable, as is the
opacity,dependingon gastriccontents.
48A A N IMA L S
A B DO M E N -C O MP AN IO N

Figure 38-6. Right lateral/A/ and left lateral(B)radiographs

of the cranialabdomen.In A, the pylorusis dependentand containsfluid. lts appearancein this view
is often confusedwith a mass or foreignbody. In B, the pylorusis nondependentand containsgas.

The gas/fluid pattern within the stomach may be influenced by
patient positioning. The gas rises to the highest point within
the patient.
Left lateral-gas in pylorus
Right lateral-gas in body and fundus
Ventrodorsal-gas in body and pyloric antrum
Dorsoventral-gas in fundus
On the right lateral view, the pylorus may appear as a round
soft-tissue opacity, which may be misidentified as a mass or foreign
body. A comparison with the left lateral view allows a redistribution
of fluid and gas, and gas may collect in the pylorus, making it
easierto identify (Fig. 38-6).
the small animal abdomen includes two views-the lateral and
ventrodorsal views.
Whether to routinely make a right or left lateral view of ttr,e
abdomen depends on viewer preference. It is important that the
positioning of the lateralview be consistent.If you chooseto make
a right iateral projection as part of the standard examination, then
the right lateral view should always be made (unless there is a
medical reasonnot to).
Other views might also be useful. The opposite lateral view
might be made to allow gas to shift into previousiy fluid-filled
portions of the GI tract (seeFig. 38-6). A dorsoventralview might
also be made to allow gas to shift, as in gastric diiation. A hori-
zontal-beam radiograph with the animal in Ieft recumbency could

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

Table 38-6. Radiographic signs of obliquity

Lateral
Rib heads are NOT superimposed(thoracicspine only)
Intervertebralforamina are NOT the same size
Transverseprocessesare NOT superimposed
Coxofemoraljoints are NOT superimposed
Ventrodorsal
The spinous processesare NOT aligned
Processestipped to the LEFTor RIGHT
Processesshaped differentlywithin an anatomic region
Sternum and spine are NOT superimposed
Rib and thoracicasymmetry
Vertebralbodies are NOT in alignment

Cranial boundaries from the entire diaphragmatic margin caudally

to the greater trochanter of the femurs (both lateral and ventro-
dorsal views)
Dorsal and the ventral soft-tissue marqins
*of of the abdomen
Medial and lateral soft-tissue margins the abdomen
It is also important that the appropriate cassettesize be selected
for the examination because if the film is too small. the entire
abdomen will not be visualized(and a lesion may be missed). If
the fiim selectedis too large, unnecessaryexpenseis added to the
cost of the examination (larger film costs more). Larger animals
may not fit onto the largest cassette(14" x17", and the use of tr,vo
cassettesfor each view (for a total of four cassettes) may be
Figure 38-8. CorrectlyiAl and incorrectly/8/ positionedlateralradiographs necessary(Fig. 38-7).
of the abdomenN . o te th a t th e p a tie n tis o b liq u e a
, n d th e enti reabdomeni s Poorly positioned film may result in an incorrect radiographic
p o sitio n e d
n o t i n c l u d e do n t h e i n co r r e ctly a b d o m e nr a d io g r aphs.
diagnosis if positioning is not considered when one is evaluating
the radiographs. When the abdomen is evaluated for signs of
obliquity, the spine can be used to determine if the abdomen was
be used to detect the presence of free peritoneai gas collecting straight or oblique (Figs.38-8 and 38-9; Table38-6).
beneaththe abdominal wall.
Protocol I lnterpretation paradigm
It is important that the following anatomic boundaries, which There are many ways to approach the radiographic interpretation
constitute a complete abdominal examination, be included: of the small animal abdomen. The steps listed here constitute one

Figure 38-9. Correctiy/A/ and incorrectly/B/ positionedven-

tr o d o r s arl a d i o g r a p hos{ th e a b d o m e n .In 8 , th e e n tir ep a tient
h a s n o t b e e n i n c l u de din th e im a g e ,a n d th e p a tie n tis r o ta ted.
49O A N IMA L S
A B DO M E N-C O MP AN IO N
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,
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
foundation to develophis or her own approach,or may help one
to become more organizedin approachingthe task of evaluating
radiographicexaminationsof the small animal abdomen.
Do not try to evaluateall structureson the lateral radiograph'
and then all structureson the VD radiograph.There are too many
structuresto allow consistentrememberingof all the changesto be
evaluatedbetween views. Go back and forth, comparing structures
on the ventrodorsal and lateral views. (Italicized structuresare not
normallv visualized.)
1. Evaluateradiographsfor technique,positioning, and phase
of respiration.Make sure that the radiographsare of high diagnos-
tic quality before proceeding.
2. Evaluate soft tissues. Progressing clockwise, begin with the
dorsal soft tissues,move to the perineum (evaiuatescrotum) and
inguinal region (evaluateinguinal lymph nodes), and finish with
Figure 38-11. Transversecomputed tomography image of a dog with a
oartiallvmineralizedadrenallumot (arrowheads).
the ty pe of
the ventral soft tissues(evaluatethe ventral abdominal body wall,
prepuce,os penis, and urethra). On the ventrodorsalview, evaluate
the body wall and the soft tissuessurrounding the abdomen.
3. Critically assessskeletalstructures(spine, ribs, pelvis, coxo-
femoral joints, femurs, and stifles).
4. Evaluatethe portion of the thorax that can be seen.Incidental
thoracic findings are often critical to making the correct diagnosis.
5. Evaluatethe diaphragm.
6. Evaluateserosalmargin detail. Rememberthat loss of detail
may be generalizedor focal dependingon the cause.
7. Evaluate the mesentericlymph nodes,Iiver, gallbladder, and
spleen.
8. Evaluate the retroperitoneal spacefor adrenal or renal alter-
ations, or for masses involving the medial iliac lymph nodes.
Comparethe detail in the retroperitonealversusthe intraperitoneal
space.Often slight detail differencesare the only radiographic sign
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
The use of computed tomography in the evaluation of small animal
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

tional and helical computed tomography scannersin the veterinary

community makes this possible. Common abdominal evaluations
include adrenal tumor assessments,radiation treatment planning,
and identification ofportosystemic shunts (Fig. 38-11).

Magnetic resonance imaging

At the present time, magnetic resonanceimaging has limited appli-
cation for evaluation of the small animal abdomen, but this is an
exciting area with expanding possibilities regarding diagnosis in
small animals.

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?

Answers begin on page727,

Figure 38-13

Figure 3t14
 CHA P T E R

39
Abdominal Masses
. CharlesR. Root

I Radiographic signs view (Fig. 39-2). Uterine enlargementoften resultsin tortuous or

Recognition and assessmentof displacementof abdominal struc- convoluted homogeneous tubular opacities in the caudoventral
tures are the keys to successful radiographic differentiation of abdomen.Furthermore,in the lateralview, there may be separation
abdominal masses.The effectsof abdominai masseson adjacent of the ventral aspect of the colon and the dorsal'aspeci of the
structuresdepend on both the degreeof enlargementand gravity. urinary bladder causedby distention of the bodv oflhe uterus.
If the mass is derived from a fixed organ, the effectsof gravity and Late^pregnancyis easilydistinguishedfrom diseaseby the presence
body position are minimal. However, if the enlarged organ is of fetal skeletal mineralization, a finding that is generilly first
pendulous, pedunculated,or mobile, the combined gravitational presentat 40 to 45 daysof gestationin dogs and cats.
and mass effects on adjacent structures may be striking. Visceral
Urinary bladder
displacement identified radiographically with the patient in dorsal
or lateral recumbency may be different from that occurring while Distention of the urinary bladder (Fig. 39-3) usually produces a
the patient is standing.Visceraldisplacementmay be due to push- homogeneoussoft-tissuemasseffectin the caudoventraiabdomen.
ing, traction, or (in hollow visceraonly) redundancy.Abdominal In the lateral projection, a full urinary bladder usually causes
massesusually causedisplacementof adjacentmobile structuresby cranial displacementof small bowel and dorsal displacementof the
pushing. Traction displacementoccurs when a structure is pulled descendingcolon. In the ventrodorsalprojection, the descending
from its normal position by some pathologic movement of a be displacedeither to the right or the left of the urinar|
!9191
structure to which it is attached(e.g.,ventral displacementof the -uyA full urinary bladder may entrap the descendingcolon
bladder.
caudal pole of a kidney by an ovarian mass;ventral displacement to the right of the midline (Fig. 39-a).
of the duodenum by a mass in the left limb of the pancreas;and
ventral displacementof the transverseand ascendingportions of
the colon by severeregionallymphadenopathy).Redundancyis the
third reason a structure appearsout of place; the elongatedde,
scendingcolon is probably the most common example.Its presence
in an atypicallocation ofthe caudalabdomen often falselysuggests
enlargementof adjacentstructures.
Severalabdominal organs undergo variation in size under nor-
mal circumstances.These are the stomach, the urinary bladder,
and the uterus. Each of these organs may be pathologicallyen-
larged, and it may be difficult to differentiate radiographically
between normal and abnormal enlargement.A1l other normally
visible abdominal organs are enlargedonly if abnormal.
The edges of enlarged visceral structures may not be directly
visible radiographically.In such instances,enlargementmust be
inferred by the direction and degreeof displacementof adjacent
structures. Such displacement may be appreciableeven in the
presenceof diminished abdominal visceraldetail.
The following is a discussionof the typical radiographic signs
associatedwith enlargementof specific abdominal organs. There
are exceptionsto the generalpatternsof visceraldisplacement,but
they are rare. The most common exceptionsto typical radiographic
signs of abdominal massesare those due to extreme enlargement
of the organ in question. Lessfrequently,redundancyof a hollow
viscusmay falselysuggestenlargementof an adjacentstructure.

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 39-2. Laleral(A)and ventrodorsal/B)abdominalradiographs of a femaLedog with pyometra.Noticethe convolutedloopsof tubularflurdopacity(uterus)

in t h e c a u d o v e n t r aalb d o m e n T. h e sm a Lbl o we l js d isp la ce dcranl odorsal land The des c endi ngc ol oni s
y, i n the ventrodorsavi ew l t i s often di spl acedmedi al l y.
a s d e p icte din th e a sso cla ted ia g r a m/C /.
of t e n d i s o l a c e d o r s a llv,

Figure 39-3. La\e"al(A)and ventrodorsal/8/ abdominaL
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.
H o s p i t a lS, a n t aC r u z,CA.)
Liver
Diffuse 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
(an imaginary line conirecting the fundus, body, and pylorus of
the stomach) should be either parallel to the ribs or perpendicular
to the spine, or somewhere between those two extremes. In the
ventrodorsal projection, the gastric axis should be perpendicular to
the spine in the dog. Becausethe pylorus may normally be more
caudal in the cat, it can be approximately 30 degreesfrom perpen-
dicular to the spine in that species,especially in the ventrodorsal
projection. In many instances,the enlarged caudoventral edge of
the abnormal liver can be seen as it projects beyond the costal
margin. However, when poor abdominal visceral detail prevents
direct visualization of the edse of the liver, disturbances in the
AbdominalMasses 495
radiographs of a dog with a historyof incontinence.The atonicurinarybladderis distended,displacing
i A and I courtesyof the S antaC ruzV eteri nary
gastric axis can still be identified if gastric contents can be seen.
Occasionally, gastrography may be necessaryto fully characterrze
hepatomegaly.
Focal lobar hepatic masses
Massesdeveloping in the right lateral or dght middle lobe of the
liver, in the absenceof diffuse hepatomegaly,often produce rather
specific visceral displacements(Fig. 39-6). There is dorsomedial
displacement of the pyloric antrum, pylorus, proximai descending
duodenum, and ascendingcolon. Furthermore, there is caudodor-
sal displacement of the adjacent small bowel loops and, if the
hepatic mass is pedunculated and sufficiently large, craniodorsal
displacement of the body of the stomach. Left lateral or left middle
lobar hepatic massescause dorsomedial displacement of the head
(proximal extremity) of the spleen, the adjacent small intestine,
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
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)
the spleen is variably displaced,but the fundus of the stomach may
be markedly displacedcraniodorsallyif entrappedby a peduncu-
lated hepatic mass of sufficient size lying to the left. It is important
to realizethat focal hepatic massescan appear radiographicallyto
be caudal to the stomach,a position not typically associatedwith
a liver mass (seeFig. 39-7).
Central lobar liver massesare rare but usually causethe body
of the stomach to be displacedcaudodorsally,creating extrinsic
indentation of its lessercurvature (Fig. 39-8). Contrast gastrogra-
phy may be necessaryfor this sign to be fully appreciated.
Spleen
Diffuse splenomegaly
Generalized enlargement of the spleen, if miid, is difficult to verify
radiographically.The spleenundergoesconsiderablenonpathologic
variation in size.Radiographicassessment of splenicsize is subjec-
tive, at best. The most acceptable criterion appears to be that a
spleenshould be consideredenlargedif its edgesare rounded and
ifit obviouslydisplaces adjacentviscera(Fig. 39-9).
Splenic masses
Massesoriginating in the head (proximal extremity) of the spleen
cause caudodorsal displacement of the adjacent small intestine in
the lateral projection. In the ventrodorsal projection, proximal
splenic massescause the small bowei to be displaced caudaliy and
to the right. Also, becausethe gastrosplenic ligament renders the
head of the spleen relatively immobile, massesof the head of the
spleen may compressand causecranial displacement of the greater
curvature of the stomach, especiallyin the ventrodorsal view (Fig.
3e-10).
Massesthat originate in the body or tail (distal extremity) of the
spleen are the most common cause of a ventral midabdominal
mass seenon the lateral view (Fig. 39-11A). Distal splenic masses
are much less consistent in their displacement of small bowel than
are those of the head becausethe tiil and body of the spleenare
more mobile (see Fig. 39-11). Generally,there is dorsal displace-
ment of some portion of the small bowel in the lateral projection.
In the ventrodorsalprojection, depending on the location of the
splenic mass, the small intestine may be displaced to the left, to
the right, caudally, cranially, or peripherally. In fact, in subsequent
radiographs, there may be considerable change in enteric visceral
displacement. Furthermore, the length of time a patient is kept in
a certain position before radiographs are made may influence the
position of the splenicmass.
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
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 root of the mesentery,however,generally produce characteristic
peripheral enteric displacementin the ventrodorsalprojection and
dorsal, cranial, and caudal displacementof the intestine in the
lateral projection (Fig. 39-13). They are easilyconfusedwith some
splenic masses,especiallythose originating from the tail or body
of the spleen.Massesderived from enlargementof the colic lymph
node causeventral and dextrolateral displacement of the ascending
colon. Such ventral colonic displacementis best seen with the
patient in left lateral recumbency(Fig. 39-1a).
Pancreas
Pancreatic massesproduce radiographic signs that vary with the
location of the mass within the pancreas.If the mass originates in
the left limb of the pancreas(Fig. 39-15), there is almost always
lateral displacement of the descending duodenum and extrinsic
displacementof the right caudal aspectof the pyloric antrum of
the stomach in the ventrodorsal projection. In the lateral projec-
tion, the duodenum is usually displaced ventrally. If the mass
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.
Identification of these radiographic signs depends on visualization
of the duodenum, sometimesrequiring administration of contrast
medium.
Kidneys
Visualization of the entire contour of the right kidney is rarely
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
the caudal pole is not visible, and if there is a homogeneoussoft-
tissueopacity on the right side of the craniodorsalportion of the
abdomen, enlargementof the right kidney should be suspected,
and adjacentvisceraldisplacementshould be assessed. Enlargement
of the right kidney produces medial and ventral displacementof
the descending duodenum and ascending colon. There is also
usually left ventral displacementof the adjacent portion of the
small intestine (Fig. 39-16).
Visualizationof the left kidney is more reliablethan that of the
right. Inability to visualizethe normal left kidney in either projec-
tion may be the first radiographic sign associated with a left
renal mass. Left renal masses often produce ventrai and medial
displacementof the descendingcolon and adjacent small bowel
(Fig. 39-17).
Renal masses,even those of considerablesize, remain dorsal
in the abdomen. The kidneys are retroperitoneal and, like all
retroperitoneal structures, are prevented from migrating ventrally
by the retroperitoneal fascia. Enlargement of retroperitoneal struc-
tures other than the kidneys is rare. In instancesof retroperitoneal
massesother than renal origin, visualizationof the ipsilateralkid-
ney should not be impaired. Renal displacementin such instances
varieswith the location of the mass.Adrenal masses,massesorigi-
nating from the epaxial spinal musculature, and massesoriginating
from one of the caudal ribs or one of the lumbar transverse
processes(Fig. 39-18) are examplesof extrarenalretroperitoneal
space-occupying lesions.One note of caution is appropriate:Adre-
nal pheochromocytoma may invade and replace ipsilateral kidney
tissue (Fig. 39-19).3 Inasmuch as renal massestend to remain
dorsal,progressiveenlargementcausesventral displacementof the
adjacent mobile visceral structures. Becausethe kidneys are lateral
to the root of the mesentery,renal massesproduce medial visceral
displacement as they enlarge.
Ovaries
Right ovarian massesare associatedwith a well-circumscribedho-
mogeneousopacity chudal to the right kidney, separateand distinct
from the caudal pole of the kidney. They produce medial, but not
ventral, displacement of the descendingduodenum and ascending
Figure 39-6. The effects of a localizedmass
i n the ri ghtl aterall obeof the l l ver.N otethat the
masscan extendcaudalto the stomac h.
colon. Furthermore, there is ventral deviation of the caudal pole
of the right kidney if the ovarian massis large enough.
Left ovarian masses,in addition to producing a space-occupying
soft-tissuemass caudal to the left kidney, usually produce medial
(but not ventral) displacementof the descendingcolon and adja-
cent small bowel (Fig. 39-20). The caudal pole of the left kidney
may be tipped ventrally, depending on the size and location of
the mass.
At first consideration,massesoriginating in the ovarieswould
seemto be capableof producing visceraldisplacementidentical to
that produced by kidney masses.They do not, however, because
ovaries are not retroperitoneal. Therefore, as an ovarian mass
enlarges, its ovarian ligament stretches,permitting it to gravitate
ventrally either between the body wall and the descending colon
(left ovarian mass),or betweenthe body wall and the descending
duodenum and ascendingcolon (right ovarian mass).As a result,
ovarian masses usually displace adjacent structures medially but
not ventraily. Consequently,visceral displacementis best seen in
the ventrodorsal view (seeFig. 39-20C and D) and is rarely appar-
ent in the lateral projection. Becausethe ovarian ligament is
attached to the caudal pole of the kidney, a sufficiently pendulous
ovary producesventral deviation of the caudal pole of the ipsilat-
eral kidney in lateral projections.
Prostate gland
Generalizedor symmetricalenlargementof the prostategland pro-
duces cranial displacement of the urinary bladder and, possibly,
dorsal displacementof the rectum (Fig. 39-21). The ventrodorsal
projection is often of little value in assessmentof the prostate
gland. It should be noted that prostatomegaly(in the absenceof
distention of the urinary bladder) can displacethe colon to either
side of the midline. If the prostate gland is painful, the coion may
be full of fecal material, as the animal may be obstipated.
Eccentric enlargement of the prostate gland, as produced by
prostatic cysts or some neoplastic infiltrates, has a variable effect
on the adjacent caudal abdominal visceral structures (Fig.39-22).
Depending on the location or site of origin of the prostatic cyst,
the urinary bladder may be displaced either cranioventrally or
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

Figu r e 3 g - 1 2 . V e n t r od o r sa l/A/a b d o m in a lr a d io g r a p h o fa dogw i thtorsi onofthespeen.B othendsofthespl eenareseenend-on,andth es pl eenhas aC -

s hap eo w i n gt o r o t a t i o nab o u tits p e d icleT. h is r e la tio n sh ip
is d ia g rammed i n B al ongw i th medi aL
di spl acement
of the descendi ng
duodenum,w hi ch i s s ometi mes
. h isp a tie n th a da n a cu teto r sio n ;la ter,the radi ographislcgnsmay becomevagueafterfl ui dhas begunto effusethroughthe s pl eni c
s eeni n t o r s i o no f t h e s p le e nT
( A
c apsu l e . c o u r t e s vo f t h e Sa n taCr u zVe te r ln a rHo y sp ita l,Sa n taC ruz,C A .)
 A bdomi nalM asses 5O 5

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

Figure 39-14. Lateralabdominalradiographof a cat with

col i c l ymphadenopathy due to l ymphosarcoma. Therei s an i l l
defi nedmassi n the mi d-abdomen. N oti cethe v entraldi s ol ac e-
ment of the ascendi ngporti onof the col on {fec esfi l l ed)and
the caudaland ventral di spl acementof the a dj ac ents matl
bow el .Theseradi ographisic gnsare typi calof enl argement of
the col i cl ymphnode i n the cat.A s the massenl argesentenc
,
di spl acement may changeto becomecrani alan d dors al (C . our-
tesy of the SantaCruzVeterinaryHospital,SantaCruz,CA.)

Figure 39-15. The radiographic signs that are typicalof a mass in

th e r ig h tlim b o f th e p a n cr e a s.
No ticethat the descendi ng duodenum
is typ ica llyd isp la ce ve y l argepancreatimasses.
d n tr a llya n d la te ral l by c
 AbdominalMasses 5,O7

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

Figu r e g g - I 7 . /8 )l a b d o m in arla d i ographsofadogw i thl efthydronephrosi s.Wi thl eftrenal

L a l e ra l( A) a n d ve n tr o d o r sa enl argement(orotherl efts ubl umbaror
ret i o p e r i t o n e m The pati enta so has a si ngl estel l ateradi opaque
a l a s s ) ,t he sm a llb o we l a n d co o n a r e u su a llyd ispl acedmedi al l yand ventral l y. cys ti cc al c ul usC
.
Diagrammatic characterization of the radiographic signs.(A and B courtesyof LouisianaState University,Baton Rouge,LA.)
 AbdominalMasses 5O9

! - ' - :: #
a d - - *l

t:;
:!rl:;ll,
iilt9lil

'111!l .',
illlllr
. iiiii!
iillt.

',::l':)
'ltl;,

Figure 39-18. Lateral /A) and ventrodorsal18l abdominalradiographsof a dog with a

c h o n d r o s a r c o moaf t he tr a n sve r se p r o ce sso f th e r ig h t6 th lu mbarvertebra.The massi s w el l
c i r c u m s c r i b eadn d c o n ta in sm u ltip lefo ci o f r a d io p a q u em ateri al .l t does not i nvol vethe
i p s i l a t e r akl i d n e y ,b ut its ve n tr a la n d m e d ia ld isp la ce m e nof t adj acentbow ei i s otherw i se
t y p i c a lo f a s u b l u mb a ro r r e tr o p e r ito n e aml a ss. ( Co u r te syof R entonV eteri naryH ospi tal .
R e n t o nW . A.)

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

-;-E"W-ffi*'*W'w @iqq"srw:' *El" wiffi. %-

s ; ' ' ' h' '
Ii
" "F

W.3le.'

F igu r e 3 9 - 2 0 . L a l e ra l( A) a n d ve n tr o d o r sa l b d o m in ar la d i ographsofadogw i thaneopl asmofthel eftovary.Therei smedi al ,butnotventral ,di s pl ac ement

/B/a
of t h e d e s c e n d i ncgo l o n.T h e lin ed r a win g ssh o w th e typ ica rl a d iographisicgnsof el t (C )andri ght/D ovari anmasses.(A and B from R ootC R :A bd omi namas s es :
The r a d i o g r a p hdi ci f f e r en tiad ia g n o sis. l c 1 5 .26,1974.)
J Am Ve t Ra d ioSo
 A bdomi nalMasses 5l I

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.

3. Root CR: Interpretation of abdominal survey radiographs. Vet Clin North Am

Gaudal sublumbar masses 4:763,\974.
Most sublumbar massesare causedby medial iliac lymphadenopa- 4. Schebitz H, Wilkens H: Atlas of Radiographic Anatomy of Dog and Cat, 3rd ed.
thy (Fig. 39-23), although other possibilities are caudal sublumbar Berlin, Paul Parey, 1977.

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

Figure 39-26. (Courtesyof South HillVeterinaryCllnic,Puyaliup,WA.)

X Ouestions A. Right lateral aspect of the liver.

B. Right kidney.
1 List those structures in the are nearly alwaysseenin abdominal C. Pancreas.
radiographs,those that are often only partially seen,and those that D. Colic lymph node.
are usually seenonly if abnormal. E. Root of the mesentery.

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
parieial, visceral, and connecting layers,which are a1l continuous.t
The parietal peritoneum, which covers the inner surface of the
abdominal cavity and is closely adhered to abdominal musculature,
separatesextraperitonealand intraperitoneal spaces.The visceral
peritoneum covers the organs of the abdominal cavity either in
whole or in part. The connectingperitoneum includesmesenteries,
omenta, and intra-abdominal ligaments.The peritoneaispace,be-
tween the parietal and visceral peritoneal layers, normally contains
only a small amount of fluid for lubrication.
The spacebetween the dorsal margin of the parietal peritoneum
and the abdominal wall is the retroperitonealspace.The retroperi-
toneal spaceis extraperitoneal and contains adrenal glands, kidneys,
ureters,major blood vessels,and lymph nodes.The retroperitoneal
spacecommunicates with the mediastinum cranially and the pelvic
canal caudally.2
Fat is usually deposited throughout the abdominal cavity, pri-
marily in the falciform ligament,the greateromentum, the mesen-
tery, and the retroperitonealspace.The presenceof intra-abdomi-
na1 fat is important for visceral organ visualization because fat
provides an interposedopacity betweenviscera(Fig. 40-1).
I Abnormal radiographic
I findings
Increased fluid opacity
Increasedamounts of fluid within the peritoneal cavity causea loss
of the differential opacity interface between soft tissue and fat.
Phrasescommonly used to describe the loss of differential opacity
include
. Loss of intra-abdominal contrast
. (Fig. a0-3). Individual viscera may be visualized, but there is
Decreasedvisualizationof serosalsurfaces
. Increasedintra-abdominal soft-tissueopacity
. Increasedintra-abdominal fluid opacity.
Causesfor loss of intra-abdominal contrast include lack of fat,
peritoneal effusion, peritonitis, and peritoneal neoplasia.A wet hair
coat, or hair coated with ultrasound gel, superimposedover the
abdomen may also create irregular opacities that appear to be
rvithin the abdomen.
Lack of intra-abdominal fat may be the result of the age of the
animal, or it may be caused by emaciation. Immature dogs and
kittens younger than a few months of age lack sufficient fat to
provide intra-abdominal contrast; thus, the abdomen appearsas
relatively uniform and homogeneous with soft-tissue oPacity. The
abdomen may also be somewhat pendulous in normal immature
patients.Emaciation causesa similar homogeneoussoft-tissue
opacity throughout the abdomen becauseof a lack of fat (seeFig.
40-lC). In emaciatedpatients, the abdomen is often tucked up,
which can be visualized on radiographs; however, the possibility of
coexistent peritonitis cannot be excluded.
Abdominal effirsion refers to increased fluid within the perito-
neal cavity. Fluid between abdominal viscera provides added overall
opacity, and it silhouettes with viscera, thereby causing a loss of
intra-abdominal contrast. Classificationof abdominal effusion is
5t6
broad and includes transudates,exudates,blood, urine, bile, and
chyle.sIn practice, all abdominal fluids are of water or soft-tissue
opacity comparableto the visceralorgans.
Peritonitis with edema and inflammation of serosalsurfacesand
adjacent fat may also cause loss of intra-abdominal contrast. In
addition, abdominal effusion is usually present with peritonitis.
Peritonealseedingof neoplasticfoci can also causea loss of intra-
abdominal contrastbecauseofthe soft-tissueopacity ofthe nodules
and possiblecoexistenteFfusion.
The radiographic appearanceof the aforementioned conditions
varies with the cause,the severity of the disease,and the relative
amount of fluid versusfat Dresent.It is a common misconceotion
that accumulationof any amount of intraperitonealfluid resuitsin
complete obliteration of serosal margins. The degree to which
serosal margin detail is obscured by fluid is determined by the
relative amounts of fat and fluid present: the more fat present, the
more fluid is neededto causecompleteobliteration of organs and
serosalmargins. Thus, organ margins may still be visible when free
fluid is presentin the intraperitonealspace.
A large volume of abdominal fluid appearsas a homogeneous
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
voiume of fluid often causesabdominal distention, with outward
protrusion of the contour of the abdominal wall. Care must be
taken because radiographs of normal immature animals may ex-
hibit similar findings. A large volume of fluid may also displace
the diaphragm cranially. If relatively mobile segments of bowel
contain gas, they often float to the highest or uppermost area
within the abdominal cavity. The presenceor absenceof coexistent
peritonitis cannot be ascertainedradiographically.
Smalleramounts of abdominal fluid or oeritonitis mav produce
a mottled, hazy, or irregular fluid opacity on survey radibgraphs
indistinctnessor blurring of the margins of soft-tissuestructures.
With small amounts of fluid, this appearancemay be the result of
interdigitation of fluid with folds in the greater omentum and
small bowel but without a total silhouette effect.aInflammation of
the peritoneum or fat may produce a similar effect. Smaller
amounts of effusion may be causedby early fluid accumulation of
a generalizedprocessor by more localizeddisease.
Manipulation of viscera during iaparotomy produces physiologic
changeswithin the abdomen that may appear comparable to peri-
tonitis on radiographs, and these changesmay be modified by the
amount of induced tissue trauma.a Solutions containing water,
electrolytes, and relatively low-molecular-weight components are
absorbedby the peritoneal membrane within 24 hours.sProtein-
aceousfluids such as serum, blood, and lymph are absorbedmore
siowly and may be present for 1 to 2 weeks. These changescan be
visualized after laparotomy, and they should not be mistaken for
more significant complications. Static or progressivefluid accumu-
Iation during this period is abnormal.
One convenient method of assessingthe intraperitoneal space
for fluid accumulation is to comoare the detail and contrast in
the intraperitonealversusthe retroperitonealspace.Becausemany
diseasesresulting in intraperitoneal fluid accumulation do not
affect the retroperitoneal space,retroperitoneal detail is often pre-
 The Peritoneal
Soace 517

Figure 40-1. Lateralviews of the abdomen.A, Obesecat. Extensive

fat deposition i n t h e fa lcifo r mo, m e n ta l,m e se n te r ic,
a n d r e tr operi toneal
areasprovidescontrastbetweenvisceraof soft-tissueopacity.B, Nor-
mal cat. Fatdepositionis lessthan that in A but is adequateto separate
a n da l l o wv i s u a l i z a tioonf visce r aC . Em a cia te ca d t.With o u tinterposed
fat, viscerasilhouette,producinga uniform,homogeneous,soft-tissue
o p a c i t yt h r o u g h o utthe a b d o m e ne, xce p tfo r g a s in th e b o wel l oops.
5 18 AN IN /IA L S
A B DO M E N -C O N /IPA N ION
served when intraperitoneal fluid has altered the serosalmargin of
bowel and other intraperitonealorgans (seeFig. 40-3). Normally,
detail and contrastin the intraperitonealand retroperitonealspaces
should be identical. However, large volumes of intra-abdominal
fluid obscurethe retroperitonealspace,even if the fluid is confined
to the intraperitonealspace.This phenomenon is due to superim-
position by the large fluid volume. Loss of contrast and detail in
the retroperitonealspaceis an indication of fluid accumulationor,
lesscommonly,inflammation. Fluid accumulationmay be confined
to the retroperitoneal space,with a normal appearanceof the
intraperitoneil space (Fig. aO- ). The most common causesof
isolaGd retroperitoneal fluid are hemorrhage and urine leakage'
Inflammation and abscessation of the retroperitonealspacemay be
causedby migrating grassawns,penetratingwounds, foreign bod-
ies, ligatures from ovariohysterectomy,and perforation of the ure-
7 Small volumes of fluid can be readily detectedand sample collec-
thra during catheterization.6'
An ill-defined nodular or granular pattern (Fig. 0-5) may be
caused by seeding of the peritoneum with multiple, metastatic
neoplasticfoci, or it may result from proteolytic enzymesescaping
from an inflamed pancreas,causingsaponificationof omental and
mesentericfat. Examples of tumors associatedwith such spread
include hemangiosarcomaof the spleenand carcinoma of various
may be usedto describe
abdominal organs.The term carcinomatosis
any cancerdisseminatedthroughout the abdomen; it may be lim-
ited to carcinomaswith this distributiont or it can be used as a
generalterm to describeloss of serosaldetail with nodularity.
Localized radiographic changesof peritoneal diseaseare most
often causedby a small amount of fluid or by localizedperitonitis
(Fig. 40-6). One of the more common causesof localizedperitoni-
tis ls acute pancreatitis.The frequency and appearanceof radio-
tt
graphic changescausedby acute pancreatitis are variable.e
Changescan usually be iocalized to the right cranial abdomen,
where the right lobe of the pancreasis closely associatedwith the
proximal duodenum and pyloric antrum, or to the midline just
iaudal to the stomach, where the left lobe of the pancreasis
located. The major radiographic abnormality is usually an in-
creased, irregular soft-tissue opacity in the right mid- to cranial
abdomen, indicating localized peritonitis (Fig. a0-7A). Abscesses,
inflammatory masses,and pseudocystsmay be sequelaeto pancre-
atitis.r2la The proximal descendingduodenum may be displaced
ventrally or toward the right to produce a broad curvature, and
the pylorus of the stomach may be displaced toward the left (see
Fig. a0-78). Lessfrequently, the transversecolon may be displaced
caudally.Bowel loops adjacentto the pancreas,such as the proximal
descending duodenum, may contain gas; they may also have loss
of tone and be dilated. Soasticitv of the duodenum has also been
Figure 4O-2, Lateralview of the abdomen of a cat with a large
vol umeof l ntraperi toneal fl ui d.H omogeneous fl ui dopac i tyi s uni formy
throughouta di stendedabdomen.Therei s no fl ui d l n the
di stri buted
space,but fasci alpl anesand organsl n the retroperi to-
retroperi toneal
nealspaceare not vi si bl ebecauseof superi mposi ti oonf the di s tended
abdomen.D i agnosrs: fel i nei nfecti ousperi toni ti s.
described.Foci of mineralization may occur in areasof fat necro-
sis.ro
The shapeor contour of the abdomen should also be evaluated.
Large amounts of abdominal effusion result in a pendulous abdo-
men. However, the abdomen may also be pendulous from other
causes,such as obesity and the muscle weaknessof Cushing's
syndrome. Emaciation usually causesthe abdomen to appear
tucked up. Trauma to the abdominal wall or localizedabdominal
pain may produce asymmetricalcontraction of abdominal mus-
cles.a
Sonography of the peritoneal space
Ultrasound is extremelyuseful for evaluatingthe peritonealspace,
especiallywhen increasedfluid opacity is detectedradiographically.
tion via fine-needleaspiration facilitatedby ultrasound guidance.
Fluid can be characterized by its echogenicity. Fluid with low
celluiar content such as urine or a transudate is anechoic (Fig.
40-8); fluid with moderate to high cellular content such as exudate,
blood, or chyle is more echoic (Figs. 40-9 and 40-10). Peritoneal
massescan be characterized as solid or cavitary (see Fig. 40-98),
and samplescan be obtainedvia fine-needleaspirationfor cytologic
evaluation.Although uncommon, peritonealmetastasiscan be de-
tectedand appearsas fingerJike projectionsof hypoechoicmaterial
scatteredthroughout the mesentery(Fig. 0-11). Samplescan be
obtained via fine-needle aspiration for confirmation.
Sonographic evaluation of the pancreashas become standard
practice for evaiuating patients suspectedof having pancreatitis or
pancreaticmassesas the pancreasis better evaluatedsonographi-
cally than on radiographs. The normal pancreas is difficult to
identifi' because of its small size, echogenicity similar to that of
surrounding fat, and lack ofa well-definedcapsule.ts'tu In addition,
gas in adjacent bowel segments often obscures the pancreatic re-
gion. Therefore, identifiable adjacent landmarks are used to scan
the pancreatic area. Patients can be scanned in dorsaltt-20or lateral
recumbencyr6using the highest frequency transducer that will pro-
vide sufficient depth penetration. The body and right limb of the
pancreascan be found by scanning the stomach in a longitudinal
plane and sliding the transducer to the right until the duodenum
can be identified. The right limb lies just dorsal to the duodenum,
medial to the right kidney, and lateral to the portal vein. Another
approach is to scan the cranial pole of the right kidney in a
longitudinal plane and move the transducer medially until the
descendingduodenum is found. The left limb of the pancreaslies
between the greater curvature of the stomach and the transverse
 The Peritoneal
Space 519

Figure 4O-3. A, Lateraisurvey radiographof the abdomenof a cat

t hat h a db e e nh i t b y a c a r .M o ttle d ,h a zy,o r ir r e g u laflu r ido p a citywi thi n
t he v e n t r a lh a l f o f t h e a b d o m e np r o d u ce sin d istin ctn e ss
o r b lu r ri ngof
the margins of soft-tissuestructures.Note that the retroperitoneal
spaceis normaland that a hip is luxateddorsally.B, Lateralcystogram
of the same cat. There is ruptureof the urinarybladder.Note how the
f luidi n t e r d i g i t a t ewsi t h b o we l lo o p sa n d m e se n te r y.

Figurc 4O4, Lateralview of the abdomenof a doo that had been

hit by a car. There is fluid opacity in the retroperitorieal space with
bl urri ngof the margi nof the l umbarmuscul ature.The s treak i ngi s due
to interdigitationof the fluid with normal retroperitoneal fat. Note the
greaterintraperitoneal detail.There is also a sacralfracturewith dorsal
displacement.Dlagnosis:retroperitoneal hemorrhage.
52O AN IM AL S
A B DO M E N -C O MP AN IO N

Figure 40-5. A, Lateralradiographof a dog with mottled or irregular

fl ui d opaci tyw i thi n the mi dventralabdomenthat appearsas an ttt-
defi nednodul arpattern.B , C l ose-upvi ew . D i agnosiss:pl eni cl ei omy o-
sarcomaw i th peri toneal seedi ng.

Figure 4O-6. Lateralview of a dog with subtle changesowing to

pe r i t o n i t i so r t o a s m alla m o u n to f fL u id T l r fa cesi n the
. h e se r o sa su
Also n o teth e g r e a te rd e tai li n the
c a u d o v e n t r a lb d o m e na r e in d istin ct.
re t r o p e r l t o n eianlc o m p a r isowith
n th e in tr a p e r ito n esp
a l a ce .Diagnosi s:
py o m e t r aw i t h s m a l lp e r fo r a tioann d p e r ito n itis.
 The Peritoneal
Space 5.21

Figure 4O-7. A, Lateralsurvey radiographof a dog with increased,irregularsoft-

t i s s u eo p a c i t yi n th e m id cr a n iato
l cr a n iaal b d o m e n o peri toni ti s,
, wi ng to l ocai i zed 8,
Ventrodorsalview, upper gastrointestinaltract series. The pylorus is displacedto
t h e l e f t , a n d t h e p r o xim a d
l u o d e n u mis b r o a d lycu r ve d.D i agnosi s:pancreati tiw s i th
p e n o a n c r e a tat cb sce ss.

Figure 40-8. Sagittalsonogram of a dog with ascites owing to

pr o t e i n - l o s i negn t e r o p a th y.
An e ch o icflu id is se e n d isse ctin gbetw een
t h e s p l e e na n d l e f t k i d n e y.T h e la cko f e ch o e sin th e flu idis consi stent
w i t h t h e f l u i db e i n go f lo w ce llu laco r n te n t.
 A N IMA L S
5 ,2 2 A B DO M E N- C OMP AN IO N
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
should be examined in both longitudinal and transverseplanes.
As has been stated earlier, the normal Pancreas is routinely
difficult to identifu; when seen, it has indistinct margins (Fig.
40-12). The normal pancreas is somewhat hypoechoic, being less
echogenicthan the spleenr6but more echogenicthan the liver.l6'tt
Occasionally,the pancreaticoduodenal vein, which lies within the
pancreasand runs parallelto the duodenum, can be identified'tt'"
The pancreasis more likely to be identified in puppies, thin dogs,
and dogs with peritoneal fluid.'6 In people, fatty infiltration of the
pancreas is associated with obesity, and age is associated with
increased pancreatic echogenicity, making the pancreas similar in
echogenicity to surrounding fat and, therefore, difficult to iden-
tifr." Perhapsa similar change occurs in dogs and cats.
Combined with history and clinical findings, ultrasound has
become a useful diagnostic aid for patients with pancre-
In patientswith mild pancreatitis,the pancreasmay
atitis.r6'2r'23-26
be uniformly hypoechoic surrounded by more echogenic fat (Fig.
40-13;.te':nIn more severeinflammation, the pancreasmay be
enlarged and contain irregularly shaped hypoechoic and hyper-
:rrril:,;,,
,,-
ir,|tli.,f.u;il : lldiii,
echoicareas(Fig. 40-14)."'17'le Other findings may include cavitary
lesions,thickened duodenum, biliary obstruction,localizedperito-
neal fluid, and dilation of the pancreaticduct.'6,2127 Hypoechoic
areas within the pancreasare likely due to inflammation, hemor-
rhage, necrosis,and edema.l7,2s,28 Hyperechoicareasmay be due
to fibrosis.28
The surrounding tissuemay be increasedin echogeni-
city owing to acoustic enhancement through hypoechoic areas or
to saponificationof mesentericfat.r2't6'2sPancreaticpseudocysts
and abscessesmay occur secondary to pancreatitis3's' A' 2e-32ithey
appear as large, mostly anechoic massesin the pancreatic area with
distal acoustic enhancement and low-level internal echoes (Fig.
40-15). They may be difficult to differentiate ultrasonographically;
ultrasound-guided aspirates are helpful in differentiating between
the two.5
Pancreaticneoplasmsare uncommon, but may be detectedsono-
graphically. Exocrine pancreatic carcinomas tend to invade the
duodenum and often metastasizeto regional lymph nodes, liver,
and the peritoneum.33Functional islet cell tumors may be benign
or malignant and should be suspected in dogs with persistent
hypogiycemia. Both types of tumors may appear as discrete hypo-
Figure 40-1O. Sagittalsonogramof a 1-year-oldDachshundwith
fi brosi ngperi toni tiw
chroni cfi bri nopurul ent s i th chyl ouse ffus i on.There
i s a l argevol umeof echoi cfl ui dw i th septaeextendi ng throughout. The
echoes w i thi n the fl ui d suggest that the fl ui d i s h i ghl y c el l ul ar.
k, Left kidney.
 The Peritoneal
Space 523

Figurc 4O-11. Sagittalsonogramof a 9-year-old dog with peritoneal

metastasis,which is seen as hypoechoic,irregulariyshaped material
i n t e r s p e r s e dt h r o u g h th e m o r e e ch o g e n icm e se n te r icfa t. A smal l
a m o u n to f a n e c h o i cp e r ito n e aflul id ca n b e se e n o n th e r ig ht edge of
lne rmage.

echoic nodules or massesin the pancreatic region.Il t6'23'34 A
potential source of error is misinterpretation of enlarged hypo-
echoic lymph nodes as pancreatic masses.3a Islet cell tumors can be
quite small and difficult to detect sonographically; therefore, a
normal examinationdoesnot rule out neoplasia.r6 Both pancreatitis
and pancreatic neoplasms may cause biliary dilation, lymphade-
nopathy, and peritoneal fluid. Hyperechoic or heterogeneous
massesare more often found in pancreatitis, and discrete hypo-
echoic nodules are more characteristic of neoplasia. The main
sonographic features that distinguish between inflammation and
neoplasia are findings of a diffusely hypoechoic pancreas in dogs
with pancreatitis and of discrete hypoechoic nodules in dogs with
neoplasms.23
lntra-abdominal calcification
Increased mineral opacity, not associatedwith the gastrointestinal
tract, can be seen in various sites within the abdomen. Focal
calcifiedbodies may be found in the peritonealspace(Fig. a0-16).
These are thought to be the result of dystrophic calcification of
necrotic mesenteric fat, and are not considered clinically signifi-
cant.3s'36Although not common, they are seenmore often in cats
than dogs. Metastatic calcification of the abdominal vasculature is
rare (Fig. 40-17) and is associatedwith abnormal calcium metabo-
lism, primarily in animals with chronic uremia,35,37 or in those
with hypothyroidism.
Free abdominal gas
Although there are many causesof free intraperitoneal gas,the two
most common are penetration of the abdominal wall, either by
surgery or by penetrating wounds, and perforation of the bowel.
However, not all bowel perforations produce free abdominal gas.38
Laparotomy is the most common causeof free abdominal gas, and
the history is usually known in this instance. Following laparotomy,
a moderate amount of gasmay persist for days to weeks.3e Penetrat-
ing abdominal wounds are usually diagnosed by physical findings.
In patients with a penetrating wound, differentiating whether free
abdominal gas is due solely to penetration of the abdomen or is the
result of concurrent organ rupture is impossible from radiographs.
A small volume of free abdominal gas is difficult to recognize
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

Figurc 40-13, Transversesonogramof the right lobe of the pan-

creasof a dog w i th mi l d pancreati ti s,
The pancreasi s les s ec hogeni c
than normaland i s seen as a tri angul ar structure,hypoec hoi to
c s ur-
roundi ngfat, l ust ventralto the l i ver and medi alto t he duodenum
(arrowhead).The pancreaticoduodenal vein is seen in cross-sectionas
a roundanechoi cstructurew i thi nthe pancreas.

Figure 40-14, Sagitta sonogramof the right lobe of the pancreas

in a d o g w i t h p a n c r e a titis. sh a p e da r e a so f d e cr e a sedand
lr r e g u la r ly
inc r e a s e d y e p r e se n tin th e p a n cr e a sju st d o r sa lto the
e c h o g e n i c i tar
duo d e n u m( d u o d ) . T h i s a co m m o na p p e a r a n ce in d o g swith m o derate
t o s e v e r eo a n c r e a t L t r s.

Figure 40-15. Sagittalsonogramof the left pancreaticregionof a dog

w i th a hi storyof chroni cvomi ti ngand a pal pabl e
abdominal mas s .There
is a large (8 cm in diameted hypoechoicmass (arrows)containingan-
echoicareas.Distalacousticenhancementis also present.A pancreatic
abscesswas found at surgery.(From Mahaffey MB: The Pancreas.In
C arteeR E (ed):P racti cal V eteri nary P hi l adel phiW
U l trasound. a,i l l i ams&
Wi l ki ns,1995,p. 59.)

Figurc 4O-16, Close-uplateraland ventrodorsalabdomina radio-
graphs of a cat with focal ca cifted bodies (arrows)in the perjtoneal
s pa c e .T h e c a l c i f i e db od ie swe r e a n r n cd e n tafin
l d ln ga n d th o ughtto
be a r e s u l to f d v s t r o o hicca lcifica tioonf n e cr o ticfa t.
beam becauseresulting bubbles are small and irregular in shape.'
Larger gas volumes may coalesceinto a larger bubble. This larger
bubble may still be difficult to recognizeon a radiograph made
with a vertical x-ray beam becauseit is superimposedover other
viscera. In addition, this larger bubble may simulate a gas-con-
taining organ,such as the stomach.Suchfree abdominalgasusually
floats to the highest point within the abdomen. In lateral recum-
bency,this point is usually under the caudal ribs or in the midab-
domen. The concurrent presenceof abdominal effusion may make
recognition of the gas bubble easierbecausethe fluid provides a
more uniform, homogeneoussoft-tissuebackground opacity (Fig.
40-1BA). A large volume of free abdominal gas is readily detected
on survey radiographsbecausethe gas providescontrast to outline
serosalsurfacesof viscera,such as bowel loops, the stomach,and
the diaphragm (seeFig. 40-188).
Becausefree gas risesto the highestportion within the abdomi-
nal cavity, free gas may be isolated from superimposed structures
by means of a horizontally directed x-ray beam. With a small
volume of gas,it may be preferableto position the patient for l0
minutes before exposureto allow most of the gas to migrate and
coalesceat the uppermost portion of the abdomen. The most
sensitive projection for detecting small volumes of gas is a lateral
view made with a horizontally directed x-ray beam, with the
patient in dorsal recumbencyand with the cranial portion of the
abdomen slightly elevated,so small amounts of gaswill accumulate
between the liver, diaphragm, and ventral abdominal wall (Fig.
Figure 4O-17- Close-uplateralview of the caudalabdomenof a 10-
year-olddog in chronicrenalfailure.The externaliliac arteries(arrows)
are v i s i b l ed u e t o m e t a sta tic
ca lcifica tio n .
The P cri tnnoel Sn:np 525
"t"-',";l
:1-." :
40-194).s A commonly used projection for documenting free gas
is a ventrodorsalview obtainedwith the patient in left recumbency
with the use of a horizontally directed x-ray beam. Gas usually
localizesunder the highestportion of the right abdominalwall (see
Fig. a0-198), which is usually under the caudal ribs. With larger
volumes of gas, the bubble may extend under the diaphragm
or along the abdominal wall caudally. Raising or lowering eitler
end of the animal shifts the point of gas accumulation.Eiposure
factors should be lowered to underexpose the abdomen, utrd the
right abdominal wall should be centeredin the x-ray beam to avoid
superimpositionof abdominal organs createdby divergenceof the
beam at its periphery.A view with the animal in right recumbency
rs not recommendedbecausethe gas bubble rises to the ieft side
and may be confusedwith gas within the fundus of the stomach.
Gasmay alsoaccumulatein the retroperitonealspace.T Retroperi-
toneal gasis most often the result of extensionof the pneumomedi-
astinum (see Chapter 30) or penetration of the abdominal wall.
Retroperitonealgas is confined to the retroperitoneal space in
the dorsal abdomen and is best seen on i lateral radiograph
(Fig.a0*20).
Abdominal wall abnormalities
Mineralization may occasionallybe visualized in the soft tissues
surrounding the abdomen. As an example, calcinosisassociated
with Cushing'ssyndrome may produce nodulut or linear calcifica-
526 AN IM AL S
A B DO M E N -C O MP AN IO N

Figure 4O-18. A, Lateralsurveyradiographof a cat with abdominal

effusionand a moderateamount of free intra-abdominal gas. Arrows,
margi nsof the gaspocket.B , Lateralsurveyradi ograph o f the abdomen
of a dog immediatelyafter laparotomy.There is a argevolume of free
abdomi nal gas that outl i nesthe caudalsurfaceof the ri ghtc rus of the
di aphragm, the crani alpol e of the ri ght ki dney,the caudals urfac eof
part of the liver,and the serosalsurfacesof some bowel loops.
 The Peritoneal
Space 5,27

Figurc 40-19. A, Lateralview of the abdomenwith the patient in

dors a lr e c u m b e n cw y i t h th e cr a n iaal b d o m e nslig h tlye le va te da nd the
us e o f a h o r i z o n t a l ldyir e cte dx- r a yb e a m . F r e e a b d o m in agl a s has
ac cu m u l a t ebde t w e e nt h e d ia p h r a g mth , e live r a, n dth e ve n tr aal bdomi
nal w a l l . D i a g n o s i sr:u p tu r e dsm a ll in te stin e 8 . , Ve n tr o d o r saview
l of
t he a b d o m e nw i t h t h e p a tie n tin le ft r e cu m b e n cya n d th e u se of a
hori z o n t a ldl yi r e c t e dx - r a yb e a m( a sin F ig .4 0 - 1 8 A) T
. h e fr e e a b d omi nal
gas p o c k e ti s l o c a t e du nd e rth e r ig h ta b d o m in awa l ll a n d is p r oj ected
s ep a r a t e l fyr o m , r a t h e rth a n su p e r im p o se od ve r ,th e a b d o m in alfl ui d.
Dia g n o s i sr :u p t u r e ds t o ma ch .

Figure 4O-2O. Lateralview of a dog that had been shot in the

caudalabdornen.There i s a l arge vol ume of gas co nfi nedto the
retroperitonealspace. There is also gas dlssectingalong the aorta
(ventralto T12 andT13)and al ongthe fasci alpl anesof t he hi ndl i mb.
5 28 AN IM AL S
A B DO M E N -C O MP AN IO N

P,lrr.iil!Ul"'
: t*:'':::::

,,rlrr.rll9ll

: ::l:a::'
,:::a

lil lfllili irl

,,,.,11t1-ll
t::ut:,ii.iil$llr:
,-,,i9ll rllr:ia'r..
lirr: iii

Figure 4O-21. A, Lateralview of the abdomen of a dog that had

beenhit by a car.Mottled,inegular gaspatternof the soft tissues
ventral to the abdominal wallis dueto abrasionsandlacerations.B,
Lateral view of the abdomen of a dog with a sharplymarginated,
tubuar gas pocket (arrows)
ventralto the abdominalwall due to an
r n g un a lh e r n i a .

tion of soft tissuesthat may be visualizedradiographically,most
often dorsally and in the ventral abdominal wa11.''Gas from a
variety of causesmay be seen in the soft tissuessurrounding the
abdomen. Abrasions with lacerations often produce a mottled,
irregular gas pattern (Fig. 0-21A). Tubular or round gas pockets
may be contained within herniated bowel loops (Fig. 40-22; see
also Fig. 40-2lB). Gas that dissects along fascial planes is most
often due to large open wounds or to upper airway perforation or
pneumomediastinum. These patterns, however, are not pathogno-
monic for the causeof the gas accumulation.

Figure 40-22. Lateralview of the ventralabdomenof a dog with

an umbi l i calherni acontai nl nga segmentof smal l b ow el .The bow el
w i thi n the herni asack,w hi ch i s fl ui dfl l l ed,i s parti al l obs
V truc tedand
has becomedi stended.

Figure 4O-23. Lateralview of the abdomenof a normaldog. Note
t h e f a t o p a c i t yw i t h i nth e r e tr o p e r ito n esp
a l a ce .lll- d e fin endo d ul arsoft-
t is s u eo p a c i t i e si n t h e ca u d a rl e tr o p e r ito n espa l a cese e n ve n t ralto L6
re p r e s e net n d - o np r o je ctio n o s f th e d e e p cir cu m fle xilia ca r teri esand
v e i n s , n o t l y m p h n o d e s. Op a cityr e su ltin gfr o m su p e r im p osi ti on
t h i g h f a s c i a lp l a n e so ve r th e r e tr o p e r ito n e spa l a ceve n tr a lto L7, as
s e e n i n t h e i l u s t r a t lo n is
, o fte n m isd ia g n o seads lym p h a d enopathy.
fhe blackdot overlyingL4 is a fi m artifact.
I Abdominal lymph nodes
Abdominal lymph nodes can be divided into two groups: parietal
and visceral.Parietallymph nodesare thosethat lie in the retroper-
itoneal space.Theselymph nodes receiveafferentlymphatics fiom
the spine, adrenal glands, kidneys, caudodorsalabdomen, pelvis,
and pelvic limbs. Efferent vesselsfrom these lymph nodes drain
into the lumbar trunk, which in turn empties into the cisterna
chyli. The more craniallylocatedof theselymph nodes may bypass
the lumbar trunk and drain directiy into the cisterna chyli. Many
of the lymph nodes are inconsistently developed, and they often
are absent. The medial iliac lymph nodes, however, the largest
lymph nodes of the sublumbar group, are constant. The medial
iliac lymph nodes, previously known as the external iliac lymph
nodes,rare located ventral to the vertebra and between the deep
circumflex iliac and external iliac arteries. Although some authors
statethat the medial iliac lymph nodes lie ventral to L5 and L6,r it
is our experienceand that of another author4 that these lymph
nodes are often located ventral to the bodies of L6 and L7. One
lymph node is usually presenton each side,but occasionallythere
are two lymph nodes on one or both sides.The medial iliac lymph
nodes receivi afferent lymphatics from the urogenital tract as well
as from other structuresin the caudal abdomen, pelvis, and pel-
vic limbs.
The visceral group of abdominal lymph nodes drain the liver,
Figure 4O-24. Latera vlew of the abdomenof a dog with lympho-
s a r c o m aT. h e m e d i a lilia clym p h n o d e sa r e e n la r g e da n d a p p earas a
s o f t - t i s s u em a s s w i t h in d istin ctm a r g in sin th e r e tr o p e r ito n eal
space
v e n t r a tl o L 6 a n d L 7 .
The Peritoneal
Space 529
of
spleen,pancreas,stomach,and intestine.The largestof this group
are the cranial mesenteric lymph nodes, which receive afferent
lymphatics from the jejunum, ileum, and pancreas.The efferent
vesselsof the viscerallymph nodes drain inio the intestinaltrunk,
which then empties into the cisterna chyli. Normal abdominal
lymph nodes are not seenon survey radiographsbecausethey are
not of sufficient size or opacity to be seen as separatestructures
(Fig.40-23).
Abnormalities of lymph nodes
Abdominal lymph nodes may be seenradiographicallyonly if they
are enlargedor mineralized.Abundant retroperitonealfat present
in most dogs also aids in providing contrast between enlarged
lymph nodesand surrounding soft-tisiuestructures.Of the pariital
lymph nodes, the medial iliac nodes are usually the only nodes
that enlarge to such a degree that they may be seen radiographi-
ca11y.Enlarged medial iliac iymph nodes appear as soft-tiisue
massesin the retroperitoneal space ventral to L6 and L7 (Fig.
40-24).If node enlargementis severe,the lymph nodesmay extend
more cranially (Fig. 40-25). Frequently, enlarged lymph nodes
displacethe descendingcolon and rectum ventrally (Fig. 40-26).
One should be cautioned, however,that a ventral course of the
colon is not an indication of iliac lymph node enlargementunless
a soft-tissuemass is present where the lymph nodes are located.
53O A B DO N/ I E N -C O MP AN IOAN
N IM AL S

ryie*W* b*PSYe"?.
-wrc*u,*Wle:tw .'wwryWW

Figure 4O-25. Lateralview of the abdomenof a dog with lympho-

sarcoma.Medi ali l ac l ymphnode enl argement l s sev ereand appears
as a soft'ti ssuemass i n the retroperi tonea
spaceex tendi ngc audal l y
from L4 i nto the D el vi ccana.

Figure 40-26, Latera view of the abdomenof a dog with lympho-

s a r c o m aA. a r g es o f t -tissu e m a ss( lym p hn o d e s)in th e r e tr o p erl toneal
s p a c ee x t e n d sf r o m L 5 in to th e p e lvicca n a l,d sp la cin gth e al r-fil ed
c o o n a n d r e c t u mv e n t r aly.

Figure 40-27. Lateralview of the abdomenof a cat with mesenteric

ymph node enl argement. The enl argedl ymph nodesappearas a s i n-
gle, ill-de{lnedsoft-tissuemass ln the midabdomen(arrows).

The colon may be normally positioned more ventral than usual
without being displaced by a mass. The most common cause of
medial iliac lymphadenopathy is neoplasia;however, inflammatory
diseasesmay also cause node enlargement. Neoplastic lymph node
involvement may be primary (e.g., lymphosarcoma) or metastatic
(i.e., from caudal abdominal or pelvic neoplasms).u'
Visceral abdominal lymph nodes are not usually seen on radio-
graphs. They rarely eniarge enough to be seen radiographically,
they tend to silhouette with surrounding organs, and they are
infrequently specifically recognized. However, cranial mesenteric
lymph nodes may occasionally enlarge sufficiently so as to be seen
as an ill-defined central abdominal mass displacing the intestine
peripherally(Frg. a0-27).
Ultrasonography of parietal
and visceral lymph nodes
Ultrasound is more sensitive than radiography for imaging lymph
nodes. Becausethe medial iliac and jejunal lymph nodes are the
largest and most.consistent in the abdominal cavity, they can be
found more often than other nodes when normal.a3Normal lymph
nodes tend to be similar in echogenicity to surrounding mesentery
and adjacent musculature,ai but knowledge of their location and
careful identification of elongated structures of uniform echotex-
ture and thin echogenic "capsules" can permit detection (Fig.
40-28). High-frequency transducers are necessary for obtaining
resolution adequatefor imaging normal lymph nodes. Lymph
nodes are generally more easily identified in young or thin ani-
mals.43When abnormal, lymph nodes tend to enlarge, and they
become more rounded and hypoechoic (Fig. 40*29).43'aa Fine-
needle aspiratesobtained with ultrasound guidance are helpful for
determining the causeof lymph node enlargement,whether due to
metastasisor inflammation. The medial iliac lymph nodes can be
found by scanning the caudal abdominal region and carefully
searching the area around the terminal portions of the aorta and
caudal vena cava. In some instances,it is easier to find the lymph
nodes by scanning in a transverse plane and looking for subtle
rounded structures with thin echogenic borders (see Fig. 40-288)
on either side of the aorta. In the sagittal plane, the lymph nodes
appear elongated(seeFig. 0-28A). The viscerallymph nodes are
more often seen when abnormal and are encountered as hypo-
echoic nodules detected during routine scanning. They are identi-
fied as lymph nodes basedon their location.a3
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.
The Peritoneal
Space 531
I The adrenal glands
The adrenal glands are located in the retroperitoneal space near
the craniomedial border of the kidneys. The left adrenal gland is
located more cranially with respect to its corresponding-kidney
than is the right adrenal gland, which is located near the hilus of
the right kidney. The right adrenal gland is bordered dorsally by
the psoas minor muscle and the crus of the diaphragm, medially
by the caudal vena cava, ventrolaterally by the right kidney, and
cranioventrally by the right lateral liver lobe. The left adrenal gland
is bordered dorsally by the psoas minor muscle, ventrally by the
spleen, laterally by the left kidney, and medially by the aorta.r
Because of their small size and soft-tissue opacitv, the adrenal
glandsare not usually seenradiographically.
Abnormalities of the adrenal glands
Adrenal glands may be seen radiographically only when they are
enlarged or mineralized. Radiographically detectableadrenal gland
enlargementmay be causedby pheochromocytoma,ascortical carci-
noma, or adenoma.a6,a7 An adrenal mass should be suspectedwhen
a soft-tissue or partially mineralized mass is present craniomedial
to a kidney; the kidney may be displaced caudolaterally by the
mass. Large Ieft adrenal masses may displace the fundus of the
stomach cranially, the transversecolon caudoventrally, and the left
kidney caudally. Masses of the right adrenal gland may be more
difficult to detect than those of the left becausethe right adrenal
gland is in close proximity to the liver. Functional adrenal tumors
(carcinomas and adenomas) occur with equal frequency in the
right and left sides of the gland; occasionally,adrenal tumors may
a8Functional adrenocortical neoplasms(carcino-
occur bilaterally.aT,
mas or adenomas)are found in 100/oto 20%oof dogs with Cushing's
syndrome.ae,so
Dystrophic mineralization of adrenal tumors may occur and may
be seen radiographicallly'o' +t.st-sz(Fig. 40-30). iladiographically
visible adrenal calcification in dogs with Cushing's syndrome is
highly suggestiveof neoplasia.In one study of dogs with functional
adrenal tumors, 92o/oand 54o/oof radiographically visible carcino-
mas and adenomas, respectively,were calcified.aTIn another study,
adrenal calcification was found in 54o/o and, 600/oof carcinomas
and adenomas,respectively.a6 Carcinomas may invade local tissues,
including the caudal vena cava, and metastasizeto the liver, lymph
nodes, lungs, and kidneys.nt,s4s6l/Vhen adrenal carcinomas are
advanced,it may not be possible to determine radiographically the
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

Figure 4O-3O. Latercl(A)and ventrodorsal/B/ abdominalradrographs of a 12-year-olddog.

A l a r g e ,p a r t i a l l m
y i n e ra lizem
d a ssis lo ca te dca u d ato
l th e sto mach,medi alto the spl een,ano
c ra n i a tl o t h e e f t k i d ne y.T h e kid n e yis d isp la ce dca u d o ve ntral lThe
y. mass i s a ma i gnant
Dheochromocvtoma.

origin of the primary masslesion.In such an instance,the metasta-
sesmay be the major radiographicfinding, although there may be
an ill-defined soft-tissuemassin the craniodorsalabdomen.
Mineralization may occur in non-neoplasticadrenalglands (Fig.
40-31). Radiographicallyvisible adrenal mineralization of un-
known etiology has been reported in cats.52'5rHistologic detection
of adrenalcalcificationwas reported rn 3.5o/oof dogs, 30o/oof cats,
and 50oloof monkeys in one study,sTand in 25o/oof catss8and, lo/o
of dogssein two other studies.Calcificationoccurred in the zona
reticularis of the adrenal cortex in the dogs, monkeys, and cats;
however, in some cats. calcification affected the entire adrenal
cortex and extended into the medulla.uuAdrenal calcification was
not correlatedwith clinical findings. The causeand pathogenesis
of adrenalcalcificationare unknown. In humans, adrenalcalcifica-
tion has been associated with intra-adrenalhemorrhage,tuberculo-
sis, Addison'sdisease,tumors (benign and malignant), cysts,Nie-
mann-Pick disease,60 and Wolman'sdisease.o'
It appears that calcification of the adrenal glands in cats is
relativelycommon, but calcificationin most animals is not suffi-
cient to be seenradiographically.A normal-sizedmineralizedadre-
nal gland in cats and dogs is likely to have no clinical significance.
Adrenal gland dysfunctionusuallycausessecondarychangesthat
are visible radiographicaliy.Radiographic findings of Cushing's
syndrome include hepatomegaly,bronchopulmonary mineraliza-
tion, dystrophic mineralization of the skin and other soft tissues,
and adrenal gland enlargementwith mineralization, when func-
tronal tumors are present.a6's2'5r
Pulmonary arterial thrombosis has
also been reported in dogs with Cushing'ssyndrome.62 Decreased
size of the heart,63os peripheral pulmonary arteries,caudal vena
cava, and liver65has been associatedwith Addison's disease.Al-

;1 1
ellriiirl9rl
i:"
.,- .1
v4 '

. ::atl:::

""1:
**F*

.-".;:.-j

Figure 4O-31. Lateralradiograph(close-upvtew)of the abdomenof

a 1 3 - y e a r - o cl da t . M i n er a lo p a citie scr a n iato
l e a ch kid n e ya r e adrenal
gla n d sw i t h c a l c i f i c a t ioonf th e zo n ar e ticu la r is.
T h isfin d in gis cli ni cal l y
ins i q n
i fi c an t .
534 AN IM AL S
A B DO M E N -C O MP AN IO N
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).
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
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
Addisons disease,s2it is probably a rare finding as no evidence of
esophagealdilation was found in a recent study of 22 affected
dogs.us
Ultrasonography of adrenal glands
Ultrasound is the most useful imaging modality for evaluating the
adrenal glands. It has been used to evaluate normal dog adrenal
glands,6e70 normal cat adrenal glands,Tt'72 and dogs with hyper-
66'6t'6ehypoadrenocorticism,T3
adrenocorticism,4T' and adrenal
masses.Tn'7s However, the ability to image the glands accurately is
highly dependenton the quality ofthe equipment,operatorexperi-
ence, and size of the patient. The highest frequency transducer that
will produce adequate penetration is recommended. If possible,
7.5- to 10.0-MHz transducersshould be used,but 5.0-MHz trans-
ducers may be necessaryto obtain adequate penetration in larger
dogs. The adrenal glands are more easily imaged in smaller patients
in which higher resolution probes can be used to obtain quality
images with adequate penetration. Overlying bowel gas often ob-
scuresthe adrenal glands.
Most patients are scanned in dorsal recumbency.To find the left
adrenal gland, scan the cranial pole of the left kidney in a longitu-
dinal plane, then slide the transducer medially to the aorta. The
left adrenal gland lies iust ventrolaterai to the aorta between the
cranial mesenteric and renal arteries. To obtain a full longitudinal
view of the adrenal gland, it may be necessaryto rotate the probe
so that the aorta will be imaged obliquely. The left adrenal gland
of the normal dog is usually described as a "peanut shell"76or
"dumbbell"" shaped structure (Fig. 40-32A). Both adrenal glands
of dogs and cats are hypoechoic to the surrounding fat and hypo-
echoic or isoechoic when compared with the renal cortex. Occa-
sionally, the adrenal gland has a layered appearance, with the
medulla being more echogenic than the cortex. This layered ap-
pearancehas been ascribedto both normalt2'78and hyperplastic
glands.T'A hlperechoic capsule can often be identified (see Fig.
80The right adrenal gland is more difficult to image,
40-328).?'1'
especiallyin larger dogs.8'After the cranial pole of the right kidney
is scanned in a sagittal plane, the transducer is moved medially to
find the caudal vena cava.The right adrenal gland lies dorsolateral
to the caudal vena cava and cranial to the renal vein. The phrenico-
abdominal veins cross the ventral surfacesof both adrenal glands
and can occasionallybe identified with high-resolution transducers.
lt is less echogenicthan the surroundingfat; however,the medullaryportionof the adrenal
c e.The adrenagll andmeas ured
The shape of the right adrenal gland of the dog is different from
that of the left. The right has been described as having a "comma-
shaped"z+or "bent-arrow" conformation.TTIn cats, both adrenal
glands are oblong and oval to bean-shaped(see Fig.40-328).7t'"
Overlying bowel gas obscuring the adrenal glands is a major prob-
lem, especiallyon the right side. If this happens,the patient or
transducer can be repositioned in an attempt to move the overlying
bowel. Sedationmay be helpful in somepatientsthat resistabdomi-
nal compression by the transducer. Imaging the adrenal glands in
the dorsal plane is an alternate method of avoiding the overlying
bowel gasproblem, and is preferredby some sonographers.8. Both
adrenalglandscan be imaged in a dorsal plane with the patient in
Iateral recumbency. An intercostal approach may be necessaryto
image the right gland.
Ultrasonographicdeterminationof adrenalsizehas been used as
an aid for evaluating dogs suspectedof having hyperadrenocorti-
cism and hypoadrenocorticism. Adrenal size may be dependent on
the age of the dog,68with middle-aged and older dogs having larger
glands. The thickness (ventrodorsal dimension) of the gland is
more accurate than adrenal length (craniocaudaldimension) or
adrenal width (mediolateral dimension) in estimating gross adrenal
size.67Adrenal gland length is proportional to body weight, but the
diameter (thicknessor width) is not.66Therefore, cross-sectional
measurements are more valuable than length in assessmentof
adrenal giand size. Adrenal gland thickness greater than 6 mm in
small-breedand 7 mm in middle-agedto older large-breeddogs
may be used as the criterion for maximum normal adrenal gland
size.68However, adrenal gland measurementsalone should not be
used to diagnose abnormalities as there is considerable overlap of
adrenal size in normal and abnormal dogs.
Ultrasound is considered useful in differentiating pituitary-de-
pendent hyperadrenocorticism(PDH) and functional adrenocorti-
cal neoplasia.66'67 In dogs with PDH, the adrenal glands have
a "plump" appearance; they are bilaterally enlarged, uniformly
hypoechoic,and normally shaped(Fig. 40-331.0e'0',u' Normal adre-
nal gland size does not rule out PDH.68 Adrenal gland tumors
cause gland enlargement with loss of normal shape and a change
in echotexture(Figs.40-34,40-35, and 40-36). Tumors may occur
bilaterally, but are most often uni1ateral.74'7s
In dogs with functional
adrenocortical tumors, the contralateral adrenal gland is often of
normal srzeT',75 and can be imaged with ultrasound. This is con-
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.

Figure 4O-35- Transversesonogramof the right adrenalgland (arrow)oI a

1 3 - ye a r - oSh
ld ihtzu wi th hyperadrenocorti ci sm. The adrenalgl andi s enl arged,
r o u n d e da, n do f m ixedechogeni ci ty contai ni ng
hyperechoinodul
c es.H i stopath-
o lo g ica lly,th e a d r e nalgl andcontai nedmyel ol i pomasand adenomas.
536 AN IM AL S
A B DO M E N -C O MP AN IO N
would atrophy.2aUltrasound is not useful in differentiating between
benign and malignant lesions as there is no consistent appearance
for a tumor type.TaMineralization may be seenin both benign and
malignant neoplasmsas well as in adrenocorticalhyperplasia.68'ta
In one report, pheochromocytomas and adenocarcinomastended
to be rounded masses;adenomas,hyperplasia,and adrenal metasta-
sis tended to appear as nodules.Tn BecausePDH-induced nodular
cortical hyperplasia may appear similar to small functional adreno-
cortical tumors, ultrasound is not useful in differentiating the
two.68Ultrasound is helpful in evaluating extension of tumors into
surrounding tissues, especially the caudal vena cava. Ultrasound-
guided biopsy and fine-needle aspiration of the adrenal gland are
not commonly performed in veterinary medicine, but they have
been reported without complication in 2 dogs and 2 cals.'o'82'e3
In six dogs with hypoadrenocorticism, the adrenal glands were
measurablysmallerthan the adrenalglands of normal dogs.'3This
was a significant change in the left adrenal gland in which the
median thicknesswas 2.4 mm in abnormal doqs and 4.1 mm in
normal dogs.
References
1. Evans HE, Christensen GC: Miller's Anatomy of the Dog, 3rd ed. Philadelphia,
WB Saunders,1993.
2. johnson DE, Christie BA: The retroperitoneum in dogs: Anatomy and clinical
significance. Comp Contin Educ Prac Yet 12:1027,1990.
3. Ettinger Sl, Barrett KA: Ascites, peritonitis, and other causesof abdominal disten-
tion. In Ettinger Sl, Feldman EC (eds): Textbook of Veterinary Internal Medicine, 4th
ed. Philadelphia, WB Saunders, 1995.
4 . O'Brien TR: The Radiographic Diagnosis ofAbdominal Disorders ofthe Dog and
Cal Philadelphia, WB Saunders, 1978
5. Boen ST: Peritoneal Dialysis in Clinical Practice. Springfield, Charles C Thomas,
1964.
6. lohnston DE, Christie BA: The retroperitoneum in dogs: Retroperitoneal infec-
tions. Comp Contin Educ Prac Vet 12:1035,1990.
7. Roush ]K, Bjorling DE, Lord P: Diseasesof the retroperitoneal space in the dog
and cat. J Am Anim Hosp Assoc 26:47,1990.
8. Root CR, Lord PF: Peritoneal carcinomatosis in the dog and cat Its radiographic
appearance.J Am Vet Radiol Soc 12:54, I97)..
9. Gibbs C, Denny HR, Minter HM, et al: Radiological features of inflammatory
conditions of the canine pancreas. J Small Anim Prcct 13:53I, 1972.
10. Kleine LJ, Hornbuckle WE: Acute pancreatitis; The radiographic findings in 182
dogs. J Am Vet Radiol Soc 19: 102, 1978.
11. Suter PF, Lowe R: Acute pancreatitis in the dog: A clinical study with emphasis
on radiographic diagnosis. Acta Radiol lsuppll (Stockh) 319:195, 1970.
Figure 40-36. Sagittalsonogramof the left adrenalgland of the
same dog as that in Figure40-30. The adrenalglandis seen as a large
(9 cm in diameter),mixed echogenicmass (arrows).The mass is a
malignantpheochromocvtoma.
12. Edwards DF, Bauer MS, Walker MA, et al: Pancreatic masses in seven doqs
following acute pancreatitis. J Am Anim Hosp Assoc 26t189,1990.
13. Salisbury SK, Lantz GC, Nelson RW, et al: Pancreatic abscessesin dogs: Six cases
(1978-1986).I Am Vet Med Assoc 193:1004,1988.
14. Wolfsheimer KJ, Hedlund CS, Pechman RD: Pancreatic pseudocyst in a dog with
chronic pancreatitis.Canine Pract 16:6, 1991.
15. Lamb CR: Abdominal ultrasonography in small animals: Examination ofthe liver,
spleen,and pancreas.J Small Anim Pract 31:6, 1990.
16. Saunders HM: Ultrasonography of the pancreas. Probl Vet Med 3:583, 1991.
17. Nyland TG, Mulvany MH, Strombeck DR: Ulirasonic features of experimentally
induced, acute pancreatitis in the dog. Vet Radiol 24:260, 1983.
18. Nyland TG, Mattoon JS, Wisner ER: Ultrasonography of the Pancreas.In Nyland
TG, Mattoon JS (eds): Veterinary Diagnostic Ultrasound. Philadelphia, WB Saunders,
1995.
19. Murtaugh RJ, Herring DS, Jacobs RM, et al: Pancreatic ultrasonography in dogs
with experimentally induced acute pancreatitis. Vet Radiol 26:27,1985.
20. Mahaffey MB: The pancreas. In Cartee RE (ed): Practical Veterinary Ultrasound.
Philadelphia, Williams & Wilkins, 1995, p 52.
21. Lamb CR: Recent developments in diagnostic imaging of the gastrointestinal tract
ofthe dog and cat. Vet CIin North Am Small Anim Pract 29:307,1999.
22. Worthen N], Beabeau D: Normal pancreatic echogenicity: Relation to age and
body fat. Am J Radiol 139:1095,1982.
23. Lamb CR, McEvoy FJ: Comparison of ultrasonographic findings in canine pancre-
atitis and pancreatic neoplasia [Abstract]. Vet Radiol Ultrasound 36:434, 1995.
24. Saunders HM, Pugh CR, Rhodes WH: Expanding applications of abdominal
ultrasonography. I Am Anim Hosp Assoc 28:369,1992.
25. Homco LD: Pancreas.In Green RW (ed): Small Animal Ultrasound. Philadelphia,
Lippincott-Raven, 1996, p 177.
26. Simpson KW, Shiroma Jl Biller DS, et al: Antemortem diagnosis of pancreatitis
in four cats. J Small Anim Pruct 35193,1994.
27. Lamb CR: Dilation of the pancreatic duct: An ultrasonographic finding in acute
pancreatitis. J Small Anim Pract 30:410, 1989.
28. Saunders HM: Ultrasonographic detection and characterization of pancreatitis in
dogs. Proceedings of the American College of Veterinary Radiology Annual Meeting,
Nov 29-Dec 1, 1990, Chicago, Illinois, p 66.
29. VanEnkevort BA, O'Brien RT, Young KM: Pancreatic pseudocystsin 4 dogs md 2
cats: Ultrasonographic and clinicopathologic findings. I Vet Intern Med 13:309, 1999.
30. Rutgers C, Herring DS, Orton C: Pancreatic pseudocyst associated with acute
pancreatitis in a dog: Ultrasonographic diagnosis. J Am Anim Hosp Assoc 2l:411,
1985.
31. Hines BL, Salisbury SK, Jakovljevic S, et al: Pancreatic pseudocyst associatedwith
chronic-active necrotizing pancreatitis in a cat. J Am Anim Hosp Assoc 32:147, 1996.
32. Barnhart MD, Smeak D: Pericolonic mass containing chyle as a presumed sequela
to chronic pancreatitis in a dog. I Am Vet Med Assoc 212:70, 1998
33. Iubb KVF, Kennedy PC, Palmer N: The Pancreas. In Jubb KVR Kennedy PC,

Palmer N (eds): Pathology of Domestic Animals, Vol 2, 3rd, ed,-Orlando, Academic
Pre ss,1 9 8 5 .
34. Lamb CR, Simpson KW, Boswood A, et al: Ultrasonography ofpancreatic neopla-
sia in the dog: A retrospective review of 16 cases.Vet Rec 137:65, 1995.
35. Lamb CR, Kleine LJ, McMillan MC: Diagnosis of calcification on abdominal
radiographs. Vet Radiol 32:211, I99I.
36. Schwarz I Morandi R Gnudi G, et al: Nodular fat necrosis in the feline and
canine abdomen. Vet Radiol Ultrasound 4l:335,2000.
37. Yaphe W, Forrester SD: Renal secondary hyperparathyroidism, pathophysiology,
diagnosis, and treatment. Comp Contin Educ Prac Vet 16i73, 1994.
38. Suter PF, Olsson SE: The diagnosis of injuries to the intestines, gall bladder and
bile ducts in the dog. J Small Anim Pract 111575,1970.
39. Probst CW Stickle RL, Bartlett PC: Duration of pneumoperitoneum in the dog.
Am I Vet Res47:176,1986.
40. Gufi! M: A Radiological Study of Hydroperitoneum and Pneumoperitoneum in
the Dog [MS thesis]. Fort Collins, CO, Colorado State University, April 1966.
41. Huntley K, Fraser j, Gibbs C, et al: The radiological features of canine Cushing's
syndrome: A review offorty-eight small cases.J Small Anim Pract 23:369,1982-
42. Leav l, Ling GV: Adenocarcinoma of the canine prostate. Cancer 22:1329, 1968.
43. Pugh CR: Ultrasonographic examination of abdominal lymph nodes in the dog.
Vet Radiol Ultrasound 35:110,1994.
44. Homco LD: Lymph nodes. In Green RW (ed): Small Animal Ultrasound. Philadel-
phia, Lippincott-Raven, 1996.
45. Schaer M: Pheochromocytoma in a dog; A case report. I Am Anim Hosp Assoc
1 6:5 8 3 ,1 9 8 0 .
46. Pennick DG, Feldman EC, Nyland TG: Radiographic features of canine hyper-
adrenocorticism caused by autonomously functioning adrenocortical tumors: 23 cases
(1978-1986).J Am Vet Med Assoc 192:1604,1988.
47. Reusch CE, Feldman EC; Canine hyperadrenocorticism due to adrenocortical
neoplasia.J Vet Intern Med 5:3, 1991.
48. Ford SL, Feldman EC, Nelson RW: Hyperadrenocorticism caused by bilateral
adrenocortical neoplasia in dogs: Four cases (1983-1988). J Am Vet Med Assoc
2021789,1993.
49. Meijer JC: Canine hlperadrenocorticism. In Kirk RW (ed): Current Veterinary
Therapy. Philadelphia, WB Saunders, 1980.
50. Owens JM, Drucker WD: Hyperadrenocorticism in the dog; Canine Cushing's
slndrome. Vet Clin North Am Small Anim Pract 7i583, 1977.
51. Huntley K, Frazer L Gibbs C, et al: The radiological features of canine Cushing's
syndrome: A review of forty-eight cases.J Small Anim Pract 23:369, 1982.
52. Ticer JW: Ro€ntgen signs of endocrine disease.Vet Clin North Am 7:465, 1977.
53. Widmer WR, Guptill L: Imaging techniques for facilitating diagnosis of hyper-
adrenocorticism in dogs and cats. J Am Vet Med Assoc 206:1857,1995.
5a. lubb KVB Kennedy PC: Pathology of Domestic Animals, 2nd ed. New York,
Academic Press,1970,p 427.
55. Kelly DF, Darke PGG: Cushing's syndrome in the dog. Vet Rec 98:28, 1976.
56. Siegel ET: Endocrine Disorders of the Dog. Philadelphia, Lea & Febiger, 1977,
p 166.
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.
58. Marine D: Calcification of the suprarenal glands of cats. J Exp Med 43:495, 1926.
59. Rajan A, Mohiyuddeen S: Pathology of the adrenal gland in canines (Caris
familiark). Indian ) Anim Sci 44:123, 1974.
60. Bergman SM, Scouras GC: Incidental bilateral adrenal calcification. Urology
22:665,1983.
61. Raafat R Hashemian MR Abrishami MA: Wolman's disease:Report of two new
caseswith a review of the literature. Am T Clin Pathol 59;490. 1973
62. Burns MG, Kelly AB, Hornof WJ, et al: Pulmonary artery thrombosis in three
dogs with hlperadrenocorticism. J Am Vet Med Assoc 178:388, 1981.
63. 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.
64. Scott DW: Hlperadrenocorticism (hlperadrenocorticoidism, hlperadrenocortical-
ism, Cushing's disease,Cushing's slndrome). Vet Clin North Am 9:3, 1979.
65. Melian C, Stefanacci J, Peterson ME, et al: Radiographic findings in dogs with
naturally-occurring primary hlpoadrenocorticism. J Am Anim Hosp Assoc 35:208,
1999.
66. Barthez Pl Nyland TG, Feldman EC: Ultrasonographic evaluation of the adrenal
glands in dogs. J Am Vet Med Assoc 207:1180,1995.
The Peritoneal
Space 5t7
67. Grooters AM, Biller DS, Miyabayashi ! et al: Evaluation of routine abdominal
ultrasonography as a technique for imaging the canine adrenal glands. J Am Anim
Hosp Assoc 30:457, 1994.
68. Grooters AM, Biller DS, Theisen SK, et al: Ultrasonographic characteristics of the
adrenal glands in dogs with pituitary-dependent hyperairenocorticism: Comparison
with normal dogs. J Vet Intern Med l0:l 10, 1996.
69. Hoerauf A, Reusch C: Ultrasonographic evaluation of the adrenal glands in
healthy dogs, dogs with no evidence of endocrine disease,and dogs with Lushing's
disease[Abstract].Vet Radiol Ultrasound j6:434,1995.
70. Douglass lP, Berry CR, lames S: Ultrasonographic adrenal gland measurements in
dogs without evidence of adrenal disease.Vet Radiol Ultrasound 3g124, Ig97.
71. Cartee RE, Finn-Bodner Sl Gray BW; Ultrasound examination of the feline
adrenalgland. I Diagn Med Sonog 9:327, 1993.
72. Zrmner C, Hoerauf A, Reusch C; Ultrasonoeraphic examination of the adrenal
gland and evaluation of the hypophyseafadrenal -axii in 20 cats. J Small Anim pract
4l :156,2000.
73. Hoerauf A, Reusch C: Ultrasonographic evaluation of adrenal glands in six dogs
with hypoadrenocorticism. J Am Anim Hosp Assoc 35:214,1999.
74. BessoJG, Penninck DG, Gliatto JM; Retrospectiveultrasonographic evaluation of
adrenal lesions in 26 dogs. Vet Radiol Ultrasound 38t448, lg97.
75. Hoerauf A, Reusch C; Ultrasonographic characteristics of both adrenal glands in
15 dogs with functional adrenocortical tumors. J Am Anim Hosp Assoc 35:193,1999.
76. Tidwell AS, Penninck DG, BessolG; lmaging of adrenal gland disorders. Vet Clin
North Am Small Anim Pract 27t232,l9g7 .
77. Schelling CG: Ultrasonography of the adrenal glands. probl Vet Med Ultrasound
3:604,1991.
78. Nyland TG, Mattoon JS, Wisner ER: Ultrasonography of the urinary tract and
adrenal glands. In Nyland TG, Mattoon JS (eds): Veterinary Diagnostic Ultrasound.
Phi l adel phi a,
W B Saunder s t995.
,
79. Homco LD: Adrenal glands. In Green RW (ed): Snall Animal Ultrasound. phila-
delphia, Lippincott-Raven, 1996.
80. Barthez Pl Nyland TG, Feldman EC: Ultrasonography of the adrenal glands in
the dog, cat, and ferret. Vet Clin North Am Small Anim pract 28:869,1998.
81. Grooters AM, Biller DS, Merryman J: Ultrasonographic parametersof normal
canine adrenal glands: Comparison to necropsy findings. Vet Radiol Ultrasound
36:126,1995.
82. Moore LE, Biller DS, Srnith TA: Use of abdominal ultrasonography in the diagno-
sis ofprimary hyperaldosteronismin a cat. J Am Vet Med Assoc2tZ:2t3, 2000.
83. Chun R, Jakovljevic S, Morrison WB, et al: Apocrine gland adenocarcinoma and
pheochromocytomain a cat. J Am Anim Hosp Asioc at3t, D97.
ffi Ouestions
l. SeeFigure 40-37, which presentslateraland ventrodorsalviews
of the abdomen of a l-year-old Rottweiler with a history of lethargy
and inappetence.Abdominal distention had been present for 2
weeks.What is the radiographicdiagnosis?
2. SeeFigure 40-38, which presentsthe lateral abdominal radio-
graph of a l3-year-old Poodle. The owner noticed a mass in
the inguinal region and another near one shoulder. What is the
radiographicdiagnosis?
3. What is the best radiographic view for detecting small quanti-
ties of free peritoneal gas using a horizontally directed x-ray beam?
A. Lateral view, patient standing
B. Lateral view patient in dorsal recumbency
C. Ventrodorsal view, patient in left lateral recumbency
D. Ventrodorsal view, patient in right lateral recumbency
4. Which of the following is least likely to result in decreased
intra-abdominal contrast?
A. Peritonitis
B. Normal puppy
C. Abdominal mass
D. Peritonealmetastasis
5. List three rule-outs for a diffuse increasein soft-tissueopacin'
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
..r]rlilllr''i11
rilirlll
:
,lll'lllirr,

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rrlllll,,r1'llo
,
1gP':.l111]1]]
r'::iii!lt,
.:
llllllll.,,r:.,.
lpll'r:i,irr
'lrll.
t,illl]lr,
"ii"iur'r:
: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
,'"liq"" i,,,,,iiil .tlllg:
. , 4 , 'r : l i
ti,.iidut.. .;!,.
-iiii

, i,iillll
irltl,,u
., 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-
sessthe liver and spleen.Radiographsprovide information about
the size, shape, margination, location, and opacity of these or-
gans.l-3Ultrasonography may also yield data about size, shape,
and location but its principal use is in assessingdiffuse or focal
parenchymalchangeswithin these organs.a-t5 In evaluating a pa-
tient with suspectedhepatic and splenic disease,radiography and
sonographyare usuallycomplementary.Under somecircumstances,
one techniquemay be more valuableor preferred.In the presence
of moderate to large volumes of abdominal fluid and in cachectic
or immature patients, ultrasound is the preferred modality. In
such patients, abdominal detail is reduced or obliterated,making
radiographicassessment of abnormalitiesof size,shape,and mar-
gination difficult. Conversely,large volumes of gastrointestinal gas
and food or free peritoneal gas significantly hamper ultrasono-
graphic evaiuation,but they affect radiographic organ assessment
to a lesserextent.With free peritonealgas,serosalmargin visualiza-
tion may be enhanced radiographically,depending on whether
peritonealfluid is also present.In addition to providing data about
the internal architectureof the liver and spleen,ultrasonography
may be used for guidance in obtaining a fine-needleaspirateor
biopsy of a lesion. Although ultrasonographicand radiographic
abnormalitiesare frequentlynonspecific,the ability to obtain accu-
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.
ablessuch as chestconformation, age,respiratoryphase,and body
position may affect the radiographic appearanceof the normal
liver. The liver appears enlarged if the thoracic cavity is overex-
panded for any reason (e.g.,respiratorydistress,pleural effusion),
and it appearssmall in animals with diaphragmatichernias and
subsequentcranial displacementof the liver into the thorax. The
conformation of the patient has a marked effect on the apparent
size and shapeof the liver. In general,deep-chesteddogs such as
Doberman pinschers,Greyhounds,and Great Danes have the ma-
jority of the liver beneath the ribs, and thus appear to have
microhepatia. Older dogs and cats may have stretching of the
coronary ligaments, which attach the liver adjacent to the dia-
phragm, causing the liver to slide caudoventrally, thus resulting in
the appearanceof hepatomegaly.Young animals in generai have
larger livers for the size of the abdominal cavity versus adults.3In
the cat, the majority of the liver is on the right side of the body,
and in most dogs, the hepatic parenchymais more symmetrically
distributed.
The normai sonographicappearanceof the liver has been thor-
oughly described.l'I2'I8'reThe canine liver has a uniform echogeni-
city, being less echoic than the adjacent spleen (Fig. 41-3) and
slightly hyperechoicor isoechoicto the renal cortex. In the normal
cat, the echogenicityrelationshipsbetweenliver, spleen,and kidney

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

Figure 41-2. Lateralradiographof the abdomen of a normal cat.

Note the abundantfat in the falciformljgamentventralto the liver.The
c a u d o v e n t r a ln g l eo f th e live ris sh a r p lym a r g in a te dwe , ll d e fined,and
lo c a t e di m m e d i a t e l yc r a n ia to
l th e flu id - fille d p ylo r u s.T h e ta i l of the
s p l e e nc a n n o tb e i d e n tifie d o n th is r a d io g r a p h
wh, ichis n o r m aforl cats.
Th e h e a do f t h e s p l e e nis visib lein th e d o r sa a l b d o m e nju st caudalto
t h e f u n d u so f t h e s t o m a ch .

are not consistent, and comparisons with adjacent falciform and
mesenteric fat are used.'?0The normal feline liver is usually less
echoic than the surrounding fat, although in some clinically normal
obese cats, the opposite relationship has been found.2l
Within the liver, two venous systemsare readily identified-the
portal venous system and the hepatic venous system. The walls of
the portal veins are hyperechoic owing to fat and fibrous connective
tissue; however, the walls of the hepatic veins are isoechoic with
the Iiver parench).rna,and thus difficult to discern, with the excep-
tion of the larger veins near the caudal vena cava (Fig. al-a).
These venous structures add a general "coarseness"to the overall
echotexture of the normal liver when comDared with the fine
granular echotexture of the spleen, and disruption of this coarse
echotexture is often seen with hepatic disease.The intrahepatic
arteries and the biliary tree ur" noi normally visible sonogriphi-
cally.
The gallbladder is readily visible in normal dogs and cats (Fig.
41-5), with thin walls (less than 1 to 2 mm)'e that are often
isoechoic with the hepatic parenchyma and the anechoic luminal
contents. The common bile duct can often be traced to the duode-
num in cats, and the normal width of the common bile duct is
less than 3 to 5 mm in cats. In normal dogs, the common bile
duct is not usually apparent sonographically.r,
Hepatomegaly
Radiographic evaluation of the liver should be based on radio-
graphic signs, or alterations of normal size, shape,margination,
opacity, and location. Enlargement of the liver is called hepatomeg-
aly, which is an objective diagnosis when made from survey radio-
graphs. The diagnosis of hepatomegaly is made by evaluation of
both_the gastric axis and the degreethat the caudoventral angie of
the liver extends beyond the caudal aspect of the ribs ai the
costochondral junction. Generalized enlargement of the liver usu-
ally causes caudal and dorsal displacement of the pvlorus and
caudal displacementoF the gastric axis (Fig. 4l-6) on'the lateral

Figure 41-3. Sonographic imageof the right cranialabdomenof a dog. The

tail of the spleen lies adjacentto the right side of the liver. The normal
echogenicityrelationshipbetween the liver (to the /eff of the image) and
the spleen can be seen. Note the smooth, sharp marginsof the left lateral
live rl o b e .
 A N IMA L S
5 ,42 A B DO M E N -C OMP AN IO N

Figurc 414. Sonographicimage of the normal liver of a dog. A

portal vein with hyperechoicwalls (blackarrowheads)and a hepatic
vein with isoechoicwalls relativeto the hepatic parenchvma/biack
arrowd are illustrated.

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 .

Figure 41-6. Lateralradiographof the abdomenof a dog with moderategeneralized

hepatomegaly. The gastrlcaxis is displacedcaudally(b/ackline);the caudoventralangle
of the l i verextendsw el l beyondthe costalarchand has a rel ati velno
y rmals hape.
 The Liverand Spleen 543

Table 41-1. Differential diagnoses for generalized Table 41-2. Differential diagnoses for focal
hepatomegaly hepatomegaly

Smooth margins lrregularmargins Neoplasia

Abscess
Hepaticvenous congestion Neoplasia-m u ltifocal,
Cyst(s)
Ne op lasia,e.9 . ,ly m phos ar c om a metastatic
Liver lobe torsion
Hyperadrenocorticism G r anulom a
Biloma
Diabetesmellitus Abscess
Acute hepatitis Nodular hy p e r p l a s i a
Early cirrhosis(cats)
ment of these possibilities. Both hepatic lipidosis and hyperadreno-
corticism are characterized by diffusely increased overall hepatic
echogenicity (greater than that of the renal cortex, equal to or
projection. On the ventrodorsal view the axis of the stomach is
greater than that of the spleen), with poor visualization of the
normally perpendicular to the spine, and it is located over the
portal vein wallsr2'18'r' (Fig. 41-8). Passivevenous congestionand
bodies of the 10th to 12th thoracic vertebrae.2''Generalizeden-
acute inflammation (e.g., hepatitis, cholangiohepatitis) are usually
largement displacesthe entire stomach caudally and to the left on
associatedwith a diffuse decreasein hepatic echogenicity, with
the ventrodorsal view and also displacesthe right kidney, transverse
increased visualization of the portal vein walls26(Fig. 41-9) and
colon, and cranial duodenal flexure caudally (Table 41-1).3 The
dilation of the intrahepatic veins and caudal vena cava in patients
more leftward position of the pylorus in cats should be kept in
with passive congestion. The sonographic appearance of diffrrse
mind when pyloric location is used as a measureof liver size. Focal
hepatic lyrnphosarcomais highly variable, including diffusely hypo-
enlargement of the liver (Tabie a1-2) may or may not affect the
echoic parenchyma, normal parenchyma, and multifocal lesions of
overall gastric axis. Evaluation of both the lateral and ventrodorsal
variable echogenicity.'7,28
views is necessaryto identify the focal hepatic enlargement and
If the caudoventral angle of the enlarged liver is not smooth,
any displacement of organs adjacent to affected liver lobes (Fig.
but irregular, lumpy, or severelyrounded in appearance,the likely
4l-7; seealso Fig. 41-6).
causesof hepatomegalyinclude neoplasia (both primary and meta-
Several authors have attempted with little successto use ultra-
static), nodular hyperplasia,hepatic abscesses, cysts,or granulomas
sound to measure hepatic size.t3-t"Moderate to severe derange- (Figs.41-10 and 41-11). The sonographicappearances of many of
ments of hepatic size (i.e., hepatic parenchyma past the level of the
these conditions are similar4' t2,28-30'thus, a definitive diagnosis
umbilicus) can be noted with ultrasound, but mild alterations in
requires cytologic or histopathologic evaluation of a sample from
hepatic volume cannot be detected reliably with ultrasound.
the abnormal liver. The common appearancesof several causesof
Once the diagnosisof diffuse hepatomegalyhas been made, the
hepatomegalywith abnormal margination are listed in Tables41-l
next criterion to be evaluated is the shape of the liver, particularly
and 4L-2.
at the caudoventral angle (i.e., that portion of the liver that extends
beyond the costal arch). If the caudoventral angle is of normal
Microhepatia
shape,or only slightly rounded, endocrine disorders such as diabe-
tes mellitus (causing hepatic lipidosis or hyperadrenocorticism), A reduction in liver size may occur with portosystemic shunting
other diffuse diseasessuch as passivevenous congestion and acute and chronic hepatitisleading to cirrhosis (Table41-3). The radio-
inflammation, and diffuse infiltrative diseasessuch as lymphosar- graphic signs used to identifr hepatic enlargement are also applied
coma should be considered (see Thble 41-l)' Ultrasound (and to diagnose a reduction in liver size. The body and pylorus of the
subsequent hepatic aspiration or biopsy) is very helpful in assess- stomach and duodenum are disolaced craniallv. This results in

Figure 41-7. Ventrodorsalradiographof the same dog as that in

F i g u r e4 1 - 6 . T h e pylo r u so f th e sto m a ch h a s b e e n d isp l acedcau-
d o m e d i a l lay n d l i e sto th e le ft o f m id lin ea t th e le ve lo f th e first l umbar
verlebra(blackarrowheads).The fundus (with rugalfolds outllnedby
gas) can be identifiedin a more normal location(blackarrowd. fhe
majorityof the hepatomegalyis right sided.
544 A B DO M E N -C ON /IPA N ION
A N IMA L S
cranial tilting ofthe stomach axis (Fig. 41-12). There is a subjective
impression of less soft tissue between the gastrointestinal tract and
the diaphragm. Focal reductions in hepatic volume result in cranial
displacement of the adjacent portion of the stomach and duode-
num. In some deep-chestedbreeds, the normal liver may be in a
reiatively cranial and ventral location, and there may be mild
cranial tilting of the stomach.
The ultrasonographic diagnosis ofmicrohepatia is subjectiveand
difficult.'z3-'?s
Microhepatia may be suspectedif the liver cannot be
seen because of interposition of the stomach when imaged from
the ventral abdomen, or of the lungs when imaged via an intercos-
tal approach.
A common cause of microhepatia is a portosystemicshunt.3r
With a shunt, portal venous blood flow from the gastrointestinal
tract bypassesthe liver and is diverted to the caudal vena cava or
azygousvein. Portosystemicshunts may be congenital or acquired.
Acquired portosystemic shunts deveiop as a consequenceof pro-
longed portal hypertension,resulting from conditions such as
chronic hepatocellular diseaseor arteriovenous fistula.32With ac-
quired portosystemic shunts, the liver size is variable, and the
radiographic findings range from severemicrohepatia to general-
ized hepatomegaly,depending on the primary cause. Unlike with
congenital shunts, ascitesmay be present. With congenital shunts,
the reduced intrahepatic blood flow and the absenceof trophic
factors causethe liver to fail to develop normally; thus microhepa-
tia is common. Bilateral, smoothly marginated mild to moderate
renomegaly may be seen with congenital shunts, in part due to
exposure of the kidneys to these trophic factors.
Shunt vesselsmay be detectedby ultrasonography.tt'to The portal
vein and caudal vena cava are best imaged in the right cranial
abdominal quadrant, either just caudal to the ribs or using an
intercostal approach. The shunt vesselsmay be identified by careful
assessment of these two large veins. Color Doppler evaluation of
the caudal vena cava for evidenceof turbulence at the junction of
the shuntine vesselwith the caudal vena cava mav focus the search.
Figure 41-8- Sonographic imageof a cat with feline lipidosis.Note the liver
is diffuselyhyperechoicrelativeto the adjacentfalciformand mesentericfat,
p o r ta lve in swith inth e l i verparen-
and n o t e t h e a b s e n c eo f e a silyid e n tlfia b le
chyma. White arrows point to the edges of the liver.
Acquired shunts are t1pically seen as multiple abnormal vessels
(varices) in the areasofthe kidneys and caudal vena cava.Reported
sensitivity rates are variable, and reliable detection of shunts is
dependent on patient preparation and cooperation, operator skill,
and equipment quality.
Tianscolonic scintigraphy has been used to confirm the presence
of a shunt(s) but offers little anatomic information.3s,16 This tech-
nique involves depositing a small volume of a radionuclide in the
terminal descendingcolon, where it is absorbed acrossthe mucosa
and into the portal venous system. Serial scintigraphic images
are rapidly made and evaiuated to determine if the radionuclide
subsequently appears first in the liver (normal) or in the heart
(shunt). Definitive diagnosis of a portosystemic shunt may be
obtained by selectiveangiography.37,38 The most common technique
is operative mesenteric portography. A jejunal vein is catheterized
at laparotomy and the abdomen temporarily closed. Water-soluble
iodinated contrast medium is iniected into the catheter, and flow
is observed either fluoroscopicily or by obtaining serial radio-
graphs. The normal intrahepatic portal circulation has a character-
istic arborizing pattern, which is usually attenuated or absent in
the presenceof a shunt. Opacification of the caudal vena cava or
azygousvein before or at the same time as the liver indicates that
a shunt is present (Figs. 4i-13 and 41-14). Shunt vesselslying
cranial to T-13 are more likely to be intrahepatic; those caudal to
this level are usually extrahepatic.3eAlternative methods include
selectivecatheterization of the cranial mesenteric artery, percutane-
ous injection into the splenic pulp, and percutaneous catheteriza-
tion of a splenic vein with ultrasound guidance.
Hepatic gas and mineralization
Gas may enter the liver via the portal or systemic circulation or by
ascending the biiiary tract. When there is gas within the vascula-
ture, branching radiolucentlines that closel/ resembleair broncho-
grams may be seenwithin the liver parenchyma.Portal gasaccumu-
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
Table 4l-3. Differential diagnoses for microhepatia
Portosystemicshunt
Cirrhosis
Chronic active hepatitis
D i a p h r a g m a t i ch e r n i a
 The Liverand Soleen 545

Figure 41-9. Sonographicimageof a dog with acute hepatitis.The

liverappearsdiffuselyhypoechoic,with increasedvisualization of portal
veins (white arrows). Black arows ooint to the edoes of the liver.

Figure 41-1O. Lateralradiographof a dog with moderateto severe

general i zed
hepatomegalwyi th i rregul ar,
roundedma rgi nsThe
. enti re
stomach is displacedcaudally(b/ackstars in lumen),and is rocated
beneathT13 and L2. Severalroundedmass{ike protuberanceslwhlte
arrows)can be seen alongthe caudoventral aspectof the liver.
546 A N IMA L S
A B DO M E N -C OMP AN IO N

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 41-13. Lateralradiographof an operativemesentericporto-

gram in a dog with multipleacquiredportosystemicshunts, Contrast
medi umhas beeni nj ectedi ntoa j ej unalvei nand passe si ntothe portal
vein (white arrows).Numerousshuntingvesselsare presentventralto
L1 and L2, and contrastmedi umcan be seen i n the caudalv ena c av a
(blackarrowheads).No evidenceof normal portal flow into the liver
i s seen.
 The Liverand Spleen 5,47

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.

Figure 41-16. Lateralradiographof a dog with biliarymineralization. Numerousirregularlymar-

g i n a t e dm i n e r a l i z ebr g u ctu r e a
d a n ch in str s r e p r e se n with
t inthe l i ver.B i l i arycal culare
i ofteni nci den-
. h e l i v eris slig h tlyd e cr e a se din size ,a s th e ca udoventral
ta l f i n d i n g sT angl eof the l i verdoes no1
e x t e n dt o t h e c o s t a lar ch .No teth e "p se u d o m a ss" of the normalfl ui d-fi l l ed
a p p e a r a nce pyl orus.
548 AN IM AL S
A B DO M E N -C OMP AN IO N

Figure 41-17. Ventrodorsal radiographof the same dog as that in

Fi gure41-16. The bi l i aryml neral i zati on
has a l i nea rpatterni n the
right side of the liver.Abdominalultrasoundwould be necessaryfor
further evaluationof the status of the biliarvtree,

Tahle 414. Ultrasonographic liver abnormalities-uniform parenchyma

Normoechoic Hyperechoic Hypoechoic Mixed echoic

Norma l Lymphosarcoma Cholangiohepatitis Lymphosarcoma
Neoplasia-LSA, MCT steroids
Hyperadrenocorticism/exogenous Hepaticvenouscongestion Cirrhosis
Amyloidosis Diabet esm ellit us Lymphosarcoma Necrosis
Acute hepatitis Hepat iclipidos is
Chronic hepatitis

LSA, lymphosarcoma; MCT mast cell tumon

Figure 41-18, Sonographicimage of a hepaticabscess.The sono-

graphi cappearance of hepati cabscessesi s i nconsi stent,
w i th c ontents
rangi ngfrom hyperechoito c anechoi c,and vari abl ydefi nedw al l s . In
this image, three round pockets of hypoechoicmaterialare present
within a largeabscessin the dorsalaspectof the centralliverin a dog.

Tabte 47-5. Ultrasonographic liver abnormalities-
focal/multifocal lesions
Mixed echoic/
Hyperechoic Hypoechoic complex
Neo pla sia e, .9..H CA Cyst (anechoic) Neoplasia
Nod ula r h yp erp las ia Hem at om a Abscess
Extramedullaryhematopoiesis Neoplas ia,e. 9. , Hematoma
Abscess LSA Necrosis
Gran ulo ma Abscess
Hema toma(matur e)
HCA, hepatocellular carcinoma; LSA, lymphosarcoma.
In experimental biliary obstruction, the first sonographic abnor-
mality is dilation of the gallbladder and common bile duct (Fig.
4I-19), which occurs 24 hours following ligation of the common
bile duct.n' TWo days following obstruction, the extrahepatic ducts
become enlarged; and the intrahepatic bile ducts are dilated 5 to 7
days following obstruction (see Fig. 41-19). Dilated bile ducts
appear as numerous branching tubes with minimally echogenic
walls near the common bile duct, and have been described as
having a "shotgun" or "too-many-tubes" appearance.ntOur clinical
impression is that dilation of intrahepatic bile ducts is uncommon
in naturally occurring biliary obstruction.
Cholecystitis, or inflammation of the gallbladder, appears sono-
graphically as thickening of the gallbladder wall. In some instances,
multiple striated layers can be seen owing to edema within the
gallbladder wall, and fluid may accumulate in the gallbladder
fossa.',n' Choleliths can also be detected with ultrasoundl these
appear as hyperechoic structures with or without acoustic shadow-
ing, located in the dependent portion of the gallbladderor bile
ducts. More common than choleliths or cholecystitis is gallbladder
sludge; this appearssonographically as hyperechoic material within
the gallbladderlumen, which settlesto the dependentportion of
the gallbladder. Gallbladder sludge is inspissated bile, which has
been describedin normal dogs as well as in dogs with hepatobiliary
disease.Biliary sludge may lead to formation of mucoceles (solid
masseswithin the gallbladder with sludge-like echogenicity),which
have been associatedwith biliary obstruction and gallbladder rup-
ture.as'aa
I Spleen
The spleen is located in the cranial abdomen, with the head
attached to the left lateral aspect of the stomach by the gastro-
splenic ligament, and the body and tail freely mobile in the midab-
domen. In most dogs, the tail of the spleen is visible on the lateral
view just caudal to the stomach along the ventral body wall, and
may blend with the caudoventral angle of the liver. The head of
the spleen is usually seen on ventrodorsal radiographs between the
fundus of the stomach, the cranial pole of the left kidney, and the
body wall, and appears as a triangular soft-tissue structure. The
head may also be seen between the fundus of the stomach and the
left kidney on lateral radiographs. In the cat, the spleen is similar
in shape, but relatively smaller. The entire spleen is most easily
seen on the ventrodorsal view along the left lateral body wall, with
distinct margins well demarcated by peritoneal fat.
On ultrasonography, the normal canine spleen appears hyper-
echoic with a fine granular echotexture and a hyperechoic capsule
(Fig. a1-20). The spleen is more echogenic than the liver or renal
cortex in the dog, and it is similar in echogenicity to the normal
prostate gland. Splenic veins are easily seen, and blood flow can
often be visible as faint hyperechoic flashes within the lumen of
the veins. In the cat, the echogenicify relationships between liver,
spleen, and kidney are much less consistent than in the dog owing
to variable fat deoosition within the liver and renal cortex in
The Liverand Spleen 549
Table 47-6. Differential diagnoses for generalized
splenomegaly
Smooth margins !rregularmargins
Neoplasia,e.9., LSA, MCT, Neoplasia-HSA, LSA, etc.
h istiocytosis Hematoma
l m m u n e - m e d i a t e dh e m o l y t i c Abscess
anemia Infarcts
Venouscongestion(RHF,portal) N o d u l a r h yp e r p l a si a
Sedationor anesthesia S p l e n i ct o r si o n
Splenitis
N o d u l a rh y p e r p l a s i a
HSA, hemangiosarcoma; LSA, lymphosarcoma; MCT, mast cell tumor;
RHE right heart failure.
normal animals.2l'a5
The spleenis often similar in echogenicityto
the surrounding peritoneal fat, and is usually found along the left
iateral body wall.
Splenomegaly
In dogs, splenic size is variable, depending on the age and activity
Ievel of the patient. Young athletic animals generally have large
spleens, whereas the spleen is smaller in sedentary or geriatric
patients. Causesof diffuse splenic enlargement include phenothi-
azine tranquilizers and barbiturate anesthetic agents, infiltrative
diseasessuch as lymphosarcoma or mast cell tumor, portal hyper-
tension, immune-mediated hemolytic anemia, and hyperplasia due
to anemia or infection (Tables 41*6 and, 41-7). The most reliable
radiographic indicator of splenic enlargementis the presenceof
rounded or blunted margins.'zOn lateral radiographs,generalized
splenic enlargementresults in caudal and dorsal displacementof
the small intestine (Fig. 41-21). Enlargementof the head of the
spleen causesrightward and caudal displacement of the small
intestineand proximal portion ofthe descendingcolon, and caudal
displacementof the left kidney on ventrodorsalradiographs.With
generalizedenlargement,the tail of the spleenmay be found in the
right cranial abdomen, resulting in medial displacementof the
descendingduodenum and ascendingcolon and cecum, or in the
midabdomen or along the left flank, extending caudally to the
bladder. In dogs, a splenic mass is the most likely source of a
midabdominal massvisible in a lateral abdominal radiograph.
Splenic size is much less variable in cats. In cats, the tail of the
spleenis seenon lateral radiographsonly if the spleenis enlarged.
Generalizedsplenomegalyproduces organ displacementssimilar to
those seenin dogs. Focal splenic enlargementcausesdisplacement
of organs adjacent to the affected portion of the spleen (Table
4l-713t Massesarising from the head of the spleen cause caudal,
medial, and ventral displacement of the small intestine and de-
scending colon, and caudal displacement of the left kidney. Masses
originating in the body and tail of the spleen are typically located
in the left or ventral midabdomen and cause caudal and dorsal
displacement of the small intestine (Fig. aI-22).
The ultrasonographic appearanceof most splenic diseases,with
the exception of splenic torsion, is relatively nonspecific. Focal
splenic diseasessuch as hemangiosarcoma, hematoma, hemangi-
oma, abscess,or other metastatic neoplasms appear as hlpoechoic
or, more commonly, mixed or complex echoic masses with or
Table 47-7. Differential diagnoses for focal
splenomegaly
Neoplasia
Hematoma
Abscess
N o d u l a rh y p e r p l a s i a
 5 5 O A B DO M E N- C OMP AN IO N
A N IN /AL S

Fi gure 41-19. S onographiicmageof the gal l bl adder and co mmonbi l e

duct i n a cat w i th i cterusand extrahepatibi
c l i aryobstructi on.In thi s i mage,
the gallbladder is normal,but the common bile duct (white curveoarrowl
i s mi l dl ydi stended (greater
than4 mm).A si ngl e,di l ated,i ntra hepatiducc t
can also be seen /open white arrow).In this cat, the causeof the obstruc-
tion was pancreatitis.

Figure 41-20. Sonographicimageof the spleenof a normaldog. A

branc h i n g s p l e n i cv e i n w i t h a n e ch o icco n te n tsis p r e se n t.T h e sp le ni c
parenc h y m h a a s a s l i g h t l yf i n e r ,m o r e g r a n u laer ch o te xtu r th
e a n d o es
t he liv e ra n d a h y p e r e c h o iocu te rca p su le .
 The Li verand Spleen 551

Figure 41-21. Laterairadiographof a dog with moderategeneral-

iz e d s p l e n o m e g a l Thy . e d o g h a s b e e n a n e sth e tizewith
d b a rbi turates
for a thoracolumbarmyelogram,The tail of the spleen is moderately
e n l a r g e da n d l o c a t e din th e m id ve n tr aal b d o m e n ;it is ca u singdorsal
d i s p l a c e m e notf s m all in te stin e s.No te th e n o r m a la p p e a r a nceof the
liver and gastric axts and the presence of contrast medium in the
ve r t e b r acl a n a l .

Figure 4r-22. Lateralradiograph of an 11-year-oldLabradorretriever

w i th a l argespl eni cmass ori gi nati ng
from the tai l o f the s pl een.Thi s
mass di spl acesthe col on dorsal l yand the smal l intes ti nesc audal l y
and dorsal l y,Mi l d to moderatebri dgi ngspondyl osis deformansi s al s o
present.The l i veri s radi ographi calnormal
ly .

Figurc 41-23. Sonographicimage of the spleen of a dog with

. h e s p l ee nwa s d iffu se lya b n o r m a with
lym p h o m a T l m u ltipl e,smal l ,
indistincthypoechoicnodules.Comparethe echotexturewith that seen
in Figure41-20.Arrowheadspoint to the marginof the spleen.
552 ABDOMEN-COMPANIONANIMALS

.tilii
llllii

Figure 41-24. Lateralradiographof a dog with splenictorsion.The

spl eeni s i n the ventralabdomen,ventralto the col on,w hi c h c ontai ns
opaquefeces. The spleen has a characteristic"C" shape sometimes
noted with splenictorsion.The slightwispy appearanceof the serosal
detai li s due to a smal lamountof peri toneal
fl ui d.

Figure 41-25. Sonographic imageof the same dog as that in Figure

41-24.fne spleen is enlargedand hypoechoic,with a lace-likepattern
ln t he o a r e n c h v m a .

Figure 41-26. Sonographicimage of a dog with splenictorsion.A

splenicvein filledwith echogenictissueis locatedbetweenthe cursors
as the spl eni cparench y ma.
and i s of si mi l arechogeni ci ty N o bl ood
flow was evidentduring real-timeimaging.The normalsplenicvessel
l umeni s anechoi c.

without internal cavities.t''L The appearanceof lymphosarcoma is
highly variable, including a diffusely hypoechoic parenchyma and
focal or multifocal hypoechoic nodules (Fig. a1-23), or the spleen
may appear sonographicallynormal.t'''?8Hyperechoicsplenic nod-
ules are frequently seen in older dogs near splenic veins; these
nodules are usually of limited clinical significance, often resulting
from hemosidetosis or mvelolipoma.aT
Splenic torsion
Torsion of the spleen occurs in large and giant deep-chested
dogs.assaThe spleentwists on its pedicle, which results in complete
occlusion of the venous drainage and eventual occlusion of the
arterial perfusion. Severesplenomegalydevelops following torsion.
The spleen may have a characteristic C-shaped appearanceon the
lateral view (Fig. 41-24).53Splenic torsion may be accompaniedby
a small to moderate volume of peritoneal fluid; this characteristic
splenic shape may be obscured by the abdominal fluid. Instead, a
large homogeneous mass may occupy the midabdomen. The fun-
dus of the stomach may be displaced caudally and medially owing
to tension on the gastrosplenicligament, and the normal triangular
soft-tissue opacity of the head of the spleen in the left cranial
quadrant on the ventrodorsal view is absent. In some instances,
anaerobic bacteria may proliferate within the spleen and causegas
accumulation with the appearance of numerous small bubbles.
Torsion of the spleen may also occur as a consequenceof gastric
volvulus.
Ultrasound is the diagnostic tool of choice to confirm a splenic
torsion. The spleen is typically severely enlarged and the paren-
chyma often has a coarse hypoechoic lace-like appearance (Fig.
4l-25).t'z,aeA similar pattern may be occasionally seen with lym-
phoma, but with lymphoma, there is normal blood flow in the
splenic veins. With splenic torsion, venous blood flow is absent,
which usually can be seen on B-mode images and confirmed by
spectral, color, or power Doppler evaluation. In some instances,
the veins are filled with echogenicthrombi rather than the expected
anechoicblood (Fig. 4I-26).
References
1. Gibbs C: Radiological features of liver disorders in dogs and cats. Vet Annu
2l:239, I98L
2. O'Brien T; Liver, spleen and pancreas. In O'Brien T (ed): Radiographic Diagnosis
ofAbdominal Disorders in the Dog and Cat. Philadelphia, WB Saunders, 1978.
3. Suter PF: Radiographic diagnosis of liver diseasein dogs and cats. Vet Clin North
Am Small Anim Pract 12:153,1982.
4. Nyland TG, Hager DA, Herring DS: Sonography of the liver, gallbladder, and
spleen.Semin Vet Med Surg Small Anim 4:13, 1989.
5. Lamb CR: Abdominal ultrasonography in small animals: Examination of the liver,
spleen and pancreas.J Small Anim Pract 31:5, 1990.
6. Biller DS, Kantrowitz B, Miyabayashi T; Ultrasonography of diffuse liver disease:
A review. I Vet Intern Med 6:71.1992.
7. England G: Renal and hepatic ultrasonography in the neonatal dog. Vet Radiol
Ultrasound 37:374, 1996.
8. Evans SM: The radiographic appearance of primary liver neoplasia in dogs. Vet
Radiol 28:193,1987.
9. Farrar ET, Washabau RJ, Saunders HM: Hepatic abscessesin dogs: 14 cases
(1982-1994). J Am Vet Med Assoc 208:243, 1996.
10. Hanson IA, Penninck DG: Ultrasonographic evaluation of a traumatic splenic
hematoma and literature review. Vet Radiol Ultrasound 35:463, 1994.
11. Lamb CR: Ultrasonography of the liver and biliary tract. Probl Vet Med 3:555,
199r.
12. Nyland TG, Mattoon JS: Veterinary Diagnostic Ultrasound. Philadelphia, WB
Saunders,1995.
13. Wrigley RH, Park RD, Konde LJ, et al: llltrasonographic features of splenic
hemangiosarcoma in dogs: l8 cases(1980-1986).J Am Vet Med Assoc 192:1113,1988.
14. Wrigley RH, Konde Ll, Park RD, et al: Ultrasonographic features of splenic
lymphosarcomain dogs: 12 cases(1980-1986).I Am Vet Med Assoc 193:1565,1988.
The Liverand Soleen 553
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.
16. Evans HE: Miller's Anatomy of the Dog, 3rd ed. philadelphia, WB Saunders, 1993.
17._Rosenzweig LJ: Anatomy of the Cat: Text and Dissection Guide. Dubuque, IA,
William C Brown, 1993.
18. Burk RL, Ackerman N: Small Animal Radiology and Ultrasonography, 2nd ed.
Philadelphia,WB Saunders,1990.
19. Kealy JK, McAllister H: Diagnostic Radiology and Ultrasonography of the Dog
and cat, 3rd ed. Philadelphia, wB Saunders, 2000.
20. YeagerAI, Mohammed H: Accuracy of ultrasonography in the detection of severe
hepatic lipidosis in cats. Am I Vet Res 53:597, 1992.
21. Nicoll RG, O'Brien RT, fackson MW: Qualitative ultrasound of the liver in obese
cats. Vet Radiol Ultrasound 39:47, 1998.
22. Spaulding KA: Gallbladder wall thickness. Vet Radiol Ultrasound 34(4):270,1993.
23. Godshalk CP, Badertscher RI, Rippy MK, et al: euantitative ultrasonic assessment
of liver size in the dog. Vet Radiol 29:162,1988.
24. Barc F: Ultrasonographic assessmentof liver size in the dog. I Small Anim pract
33:359, 1992.
25. Barr F: Normal hepatic measurements in mature dogs. I Small Anim pract
331367,1992.
26. Newell SM, Selcer BA, Girard E, et al: Correlation between sonographic findings
and specific hepatic diseasesin the cat-72 cases(1985-1997). I Am Vet Med Assoc
213:94,1998.
27. Nyland TG: Ultrasonic patterns of canine hepatic lymphosarcoma. Vet Radiol
25:167,1984.
28. Lamb CR, Hartzband LE, Tidwell AS, et al: Ultrasonic findings in hepatic and
spleniclymphosarcomain dogs and cats.Vet Radiol 32:117,1991.
29. Whitely MB, Feeney DA, Whitely LO, et al: Ultrasonographic appearance of
primary and metastatic canine hepatic tumors: A review of 4g .ar.r. J Ultrasound
M ed 8:621,1989.
30. Stowater JL, Lamb CR, Rhodes WH: Ultrasonographic features of canine nodular
hyperplasia. Vet Radiol 3l:268, 1990.
31. Martin R: Portosystemic shunts. Semin Vet Med Surg Small Anim Sl5, 1990.
32. Rogers WA, Suter PF, Breznock EM, et al: Intrahepatic arteriovenous fistulae in a
dog resulting in portal hypertension, portacaval shunis, and reversal of portal blood
flow. I Am Anim Hosp Assoc 13:470, 1927.
33. Wrigley RH, Konde LJ, Park RD, et al: Ultrasonographic diagnosis of portacaval
shunts in young dogs. I Am Vet Med Assoc lglt421, IrBj.
34. Lamb CR: Ultrasonographic diagnosis of congenital portosystemic shunts in dogs:
Results of a prospective study. Vet Radiol Ultrasound 37:281, 1996.
35. Meyer HR Rothuizen f, van den Brom WE, et al: euantitation of portosystemic
shunting in dogs by ultrasound-guided injection of 99MTc-macroaggregates into a
splenic vein. Res Vet Sci 57:58, 1994.
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
Assoc 196:925,1990.
37. Suter PF: Portal vein anomalies in the dog: Their angiographic diagnosis. J Am
Vet Radiol Soc 16:84,1975.
38. Schmidt S, Suter PF: Angiography of the hepatic and portal venous system in the
dog and cat: An investigative method. Vet Radiol 2l:57, 1980.
39. Birchard SL Biller DS, Johnson SE: Differentiation of intraheoatic versus extrahe-
patic portosystemic shunts in dogs using positive-contrast portography. J Am Anim
Hosp Assoc 25:13,1989.
40. Lord PF, Carb A, Halliwell WH, et al; Emphysematous hepatic abscessassociated
with trauma, necrotic hepatic nodular hlperplasia and adenoma in a dog: A case
history report. Vet Radiol 23:46, 1982.
41. TG, Gillett NA: Sonographic evaluation of experimental bile duct ligation
-Nyland
in the dog. Vet Radiol 23(6):252, 1982.
42. Rivers BJ, Walter PA, lohnston GR, et al: Acalculous cholecystitis in four canine
cases: Ultrasonographic findings and use of ultrasonographic-guided percutaneous
cholecystocentesisin diagnosis. J Am Arim Hosp Assoc a3:407,1997.
43. Newell SM, Selcer BA, Mahaffey MB, et al: Gallbladder mucocele causing biliary
obstruction in two dogs: Ultrasonographic, scintigraphic and pathologic n"aings. )
Am Anim Hosp Assoc 3I:467,1995.
44. Besso JG, Wigley RH, Gliatto JM, et al tlltrasonographic and clinical findings in
14 dogs with gallbladder mucocele. Vet Radiol Ultrasound 41:26I,2000.
45. Walter PA, lohnston GR, Feeney DA, O'Brien TD: Renal ultrasonography in
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
Radiol Soc 15:26, 1974.
47. Walzer C, Hittmair K, Walzerwagner C: Ultrasonographic identification and char-
acterization of splenic nodular lipomatosis or myelolipomas in cheetahs (Acinonyx
jubatus). Yet Radiol Ultrasound 37(4):289, 1996.
48. Hurley RE, Stone MS: Isolated torsion ofthe splenic pedicle in a dog. I Am Anim
Hosp Assoc 30:119, 1994.
49. Konde LJ, Wrigley RH, Lebel JL, et al: Sonographic and radiographic changes
associatedwith splenic torsion in the dog. Vet Radiol 30:41, 1989.
50. Nagel ML, Tellhelm B, Haasper A: Splenic emphysema and torsion in a dog.
Kleintierpraxis33:135, 1988.
argy. Which of the following statementsis most correct regarding
the radiographic diagnosis?
A. The large mass in the center of the abdomen is most likely
associatedwith the GI tract.
B. The large mass in the center of the abdomen is most likely
associatedwith the left kidney.
C. The large mass in the center of the abdomen is most likely
associatedwith the soleen.
D. The large mass in thi center of the abdomen is most likely
associatedwith the liver.

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-
raphy can contribute much information toward the diagnosis of
renal and ureteral diseases.The external boundaries of the kidneys
can usuallybe identified on surveyradiographs.This identification
permits assessment of the size,shape,and radiographicopacity of
the kidneys, which may aid in the diagnosisof diseaseprocesses.
However, when the kidneys cannot be assessedby survey radio-
graphs, or when qualitative functional information is needed,ultra-
sonography or excretory urography may provide the ciinician with
imoortant information.
ihe general goals of this chapter are to specifu the radiographic
and ultiasonographicimaging proceduresapplicableto the kidneys
and ureters and to place each of theseproceduresinto perspective
regarding indications, limitations, contraindications,and pitfalls
when applicable. Subsequently,the normal radiographic findings
basedon roentgen signs are described.In addition, the abnormal
radiographic findings are described,and at least a partial list of
gamutsthat should be consideredin associationwith certain roent-
gen signs is presented.
lmaging procedures
Survey radiographs provide information on the external anatomy
of the kidneys when contrast is adequateto permit their visualiza-
tion. In addition, it is possibleto assessany abnormal opacities
near the kidneys, such as air and mineral, that may suggest a
pathophysiologicmechanism for the clinical signs of renal disease.'''
Becausethe right lateral view permits greaterlongitudinal separa-
tion of the radiographic images of the right and left kidneys' it
is the projection most applicable to radiography of the upper
urinary tract.3
Survey radiographsmay not provide adequatemorphologic in-
formation when the patient is emaciated or has peritoneal or
retroperitoneal fluid. Excretory urography is useful for defining
anatomic structuresand for assessing qualitativelythe function of
the kidneys. It is a relatively simple means of verifring and localiz-
ing upper urinary tract disease,and it may be used to assessthe
reversibility of renal disease.Although excretory urography is not
a quantitative measurement of renal function, it may be used to
assiss the relative function of the kidneys and may be loosely
interpreted to assessthe pathophysiologic mechanismsof renal fail-
ure.n
Excretory urography may be used in both azotemic and nonazo-
temic patients, provided hydration is adequate. As the degree of
renal failure progresses,however, it may be necessaryto increase
the dose of contrast medium to provide adequatevisualizationof
the kidneys. In any instance, patient hydration should be assessed
and determined to be normal before any contrast medium is
administered.' It is possible that there may be a temporary decrease
in kidney function after excretory urography; an in-depth discus-
sion of this is beyond the scope of this text. The clinical significance
of this decreasedfunction is considered minimal in the presence
of adequateurinary output and patient hydration.
Azotemia is not a contraindication in excretory urography' pro-
vided the patient is adequatelyhydrated. For information concern-
ing the specific pathophysiotogy and management of patients with
556
the unlikely occurrenceof contrast medium-induced renal disease
or failure, readersare directedto textbookson renal disease.t'2
The technique of excretory urography is described in detail in
TabIe 42-I. The patient should be prepared as for survey radio-
graphs:Food is withheld, and cleansingenemasare administered.'u
Generally,ionic iodinated contrast media are used and are given by
bolus intravenous injection. However, if previous systemicreactions
(e.g., shock) have occurred in the patient, or if the patient is
severelycompromised medically, nonionic contrast media, such
as iopamidol and iohexol, or an alternative procedure such as
ultrasonographyshouid be considered.The dose of contrast me-
dium for excretoryurography is 400 mg iodine per pound ofbody
weight injected via a preplacedcephalicvenous or jugular venous
catheter.a-7 Catheter placement should be maintained for at least
15 to 20 minutes after administration of the contrast medium
becauseit provides a readily accessibleroute in the event of a
hypotensive reaction to the contrast medium. There are many
suggestedfilming sequences; however,radiographsobtained imme-
diately and 5, 20, and 40 minutes after injection of contrast me-
dium generallyyield the most information.l' s'7
The interpretative phasesof the excretory urogram are the
nephrographicand pyelographicphases.Opacificationof the func-
tional renal parenchymais the nephrogram, and opacification of
the renal pelvis, pelvic recesses,and ureters is the pyelogram.
Each phase should be evaluatedseparately(based on subsequent
information in this chapter).Although proceduresin which radio-
graphic contrast media are used provide considerableinformation
relativeto urinary tract disease,they may complicatesome subse-
quent determinations for as long as 24 hours. For example, in-
Table 42-1. Technique for excretory urography
Provideroutine patient preparation
Allow 24 hourswithout food; water ad libitum
Performcleansingenema at least 2 hours before radiography
Assesshydrationstatus;proceedonly if normal
Obtain survey radiographs
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
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 )
Dose:400 mg iodine/lbbody weight
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
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
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
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 :
Ventrodorsalviews at 5 to 20 seconds,5 minutes,20 minutes,
and 40 minutes post injectionfor generalassessment
Lateralview at 5 minutes post injectionfor general
ASSESSMENI
Oblique views at 3 to 5 minutes post injectionfor ureteral
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
Lateraland ventrodorsalviews at 30 to 40 minutes post
injectionto observe urinary bladder if retrograde
cystographyis contraindicatedor impossible
Modified from Feenev DA, Barber DL, Johnston GR, et al: The excretorY
urogram: Techniques, normal radiographic appearance and misinterpreta-
tion. Comp Contin Ed Vet Pract 4:233, 1982.
 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.

Normal imaging findings

The normal quantitativeradiographicfindings for the dog and cat
kidney and ureter are iisted in Table 42-2. The most widely used
quantification of normal kidney size in the dog and cat is renal
length, assessed on survey radiographs.r,r-5, 7,1618In general,the
dog kidney is approximately three times the length of the L2
vertebral body as visualized on the ventrodorsal view. The normal
range of kidney size in the dog is from 2.5 to 3.5 times the length
of L2.7't6 In the cat, the most acceptedrenal length is that of 2.4
to 3 times the length of the L2 vertebral body,r?but other values
have been suggested.'8 However, in the authors' experience,it is
not uncommon for cats older than 10 years of age to have a renal
length less than 2.4 times the length of L2. This suggestionhas
been supported by others.t'gThereis no direct associationbetween
the apparent small kidney size and laboratory evidenceof renal
failure when the kidney length is between 2 and 2.4 times the
length of L2. Therefore, care must be taken not to overemphasize
the significance of a renal size that is slightly outside the accepted
normal range in cats.
Other quantitative measurementsvisible only on excretory uro-
grams that may be used to assessthe kidneys include measurement
of the pyelographic variables, including the width of the pelvic
recesses,renal pelvis, and proximal ureter. In general, the renal
pelvis and pelvic recesses(sometimes referred to as pelvic diverti-
cula) in the dog do not exceed I or 2 mm in diameter, and the
proximal ureter in the dog does not exceed2 or 3 mm in diameter
(seeTable42-2).?
The shape of the dog kidney is somewhat elongated, resembling
that of a bean, whereasthat of the cat is somewhat more rounded,
although still somewhat elongated(Figs. 42-1 and 42-2).r,a6 The
right kidney is usually more cranial than the left and, as mentioned
previously, this separation can be enhanced on the right lateral
Renal opacity on survey radiographs is that of homogeneous
soft tissue.'.3Visualization of the kidneys on survey radi6graphs
relies_on the presenceof retroperitoneal fat (perirenal fat) sur-
rounding the kidneys. During excretory ntogruphy, the nephrogram
is homogeneous,with the exception of the earfy combinei vasiular
and tubular nephrograms,in which the cortex is more radiopaque
than the medulla.,,r0 The pyelogram in the normally functioning
kidney is more radiopaque than the nephrogram (see Figs. 42-i
and 42-2).
dynamic aspectsof excretoryurographylie in the assessment
^The
of nephrographicopacificationand fading sequences.a,20 Visualiza-
tion of renal opacification following intravenous injection of iodin-
ated contrast medium is dependent on (1) renal blood flow, (2)
glomerular filtration of the contrast medium, and (3) tubular
reabsorptionof water, resulting in concentrationof contrast me-
dium in the tubules. The normal nephrogram should be most
radiopaquewithin 10 to 30 secondsaftei bolus infection ofcontrast
medium.-With increasingdelay after injection, ihe nephrographic
opacity should decreaseprogressively;fewer than 25Vo of noimal
dogs have a detectable nephrographic opacity 2 hours after injec-
tion. The pyelogramshould be consistentlyopaque,and the diame-
ter of the ureter should vary with time due to peristalsis (see Figs.
42-7 and 42-2). The degree of nephrographic and pyelographic
opacification in combination with the opacification and-fadine
patterns of the nephrogram can be used as a qualitativeestimati
of renal function.6,2IIn general,the poorer the renal function, the
less opacified are the nephrographic and pyelographic phases of
tne excretory urogram.
Sonographically,the parts of the kidney that are routinely seen
.
include the cortex, the medullary papillas, the arcuate vesselsand
pelvic recessinterfaces,the renal vessels(in the hilus), and the fat
in the renal hilus (Fig. 42-3).The renal pelvis is usually not seen.
558 AN IM AL S
A B DO M E N-C O MP AN IO N

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

Number. Renal aplasia or agenesismay result in the inability to

Unilateralrenal agenesismay result
identi$r one of the kidneys.t'2'26
in compensatory hypertrophy of the unaffected kidney (Fig. az-a).
There is also the possibility that more than the expected number
of kidneys developed through renal duplication." The inability to
visualize a kidney radiographically may be merely the result of
extreme hypoplasia, the consequencesof chronic disease,or both.
Size, shape, and margination. The combination of thesethree
factors, when applied to the abnormal appearanceof the kidneys'
may aid the interpreter in limiting the possible considerations to a
manageablenumberr 3'6' I0'r8''zHo(listed below by size and shape
variabilitv):
*Depending on the stage of familial renal diseaseand the breed of dog
involved, the kidneys may appear nearly normal, small, and smooth, or
small and irregular.alTt Familial renal disease has been reported in the
fol l ow i ng breeds: S amoyed, C how C how , N ew foundl and , D oberman
pi nscher, R ottw ei l er, S tandard P oodl e, C hi nese S har pei , S oft C oated
Wheaten Terrier, Cocker spaniel, Norwegian Elkhound, Bull terrier, Old
English Sheepdog, Golden Retriever, Keesond, English Foxhound, Bernese
Mountain Dog, Basenji, Lhasa Apso, Shih tzu, German shepherd, Dutch
Kooiker, and Cavalier King Charles Spaniel. Familial renal diseasein cats
has been recognized in two forms, including the multicavitary appearance
of feline polycystic diseaseand the infiltrative appearance of feline amy-
loidosis.35' 72't3
 The Kidneysand Ureters 559

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.

Figure 42-3, Sagittal ultrasonogramof a normal right canine kidney as

v i e w e dt h r o u g ht h e l ive r T. h e r e n a lco r te xic) ,th e r e n a lm e d ul l ai m),the renal Figure 424. Radiographmade as part of an excretoryurogram.The left
s i n u s f a t ( s ) , a n d t h e e ch o g e n icva scu la rstr u ctu r e sa t th e corti comedul l ary ki dneyi s enl argedbut i s anatomi cal and
l y functi onal lnormal
y The
. ri ghtk i dney
ju n c t i o nc a n b e i d e n tifie d . i s not vi suai zed.The l eft ki dneyhas undergone functj onal
and anatomi cc om-
pensatoryhypertrophy.

=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.

Large size,regular shape and margin describedfor radiographicinterpretationapply to ultrasonographic

. Compensatory hypertrophy interpretation. However, with ultrasonography, the internal archi-
. Lymphosarcoma tecture can be visualized regardlessof the renal functional status.
. Hydronephrosis The interpretationshould still be basedon focal or diffuse diseases
. Dioctophyma renale of the parenchyma, or diseasesof the renal collecting system and
. Amyloidosis ureter. The advantage of ultrasound is the ease with which the
. Glomerulonephritis extent of the diseasecan be determined within the kidney for focal
. Perirenal pseudocyst disease(Fig. 42-8), and the easeof assessmentof renal pelvic or
. Large solitary renal cyst ureteral dilation when fluid-distended (Fig. a2-9). The location
Large size,irregular shapeand margin and relevanceof renal mineralization can also be assessed.This is
. Focal particularly relevant for survey radiographically identifiable focal
. Primary tumor (Fig. 42-6) renal pelvic region mineralization and the question of whether or
. Metastatic tumor not it is causinghydronephrosis.
. Hematoma A linear areaofincreasedmedullary echogenicitynear and paral-
. Perirenal pseudocyst lel to the corticomedullary junction has been referred to as the
. Diffuse medullary rim sign.2aIn a recent report, the relevanceof this
. Polycystic renal disease(Fig. a2-7) nonspecific sign was given perspectiveshared by the authors of this
. Feline infectiousperitonitis chapter.2aHistologically, it is an area of tubular mineralization that
. Lymphosarcoma has no specificassociationwith any given categoryof diseaseand
is not a predictabie indicator of renal dysfunction. It may, in fact,
The same principles of size, shape,margination, and number
be an observation that indicates some degree of renal insult or

Figure 42-6. Ventrodorsalview of a patient 5 minutes after intravenous

contrastmedium injectionfor excretoryurography.In the midportionof the left Figure 42-7. Lateralview of a cat 5 minutes after intravenouscontrast
k idneyt,h e r e i s a f o c a la r e ao f n e p h r o g r a p hnico n o p a cifica tio with
n compres- medium injectionfor excretoryurography.Kidneysare enlarged,and nephro-
s ionan d d i s t o r t i o no f t h e r en a lp e lvisa n d p e lvicr e ce sse sin th e a d iacentarea. graphi copaci fi catl on
i s vari abl ei n a random,patchyappearance.
Mi c ros c opi c
M ic ros c o p idc i a g n o s i sr:e n a la d e n o ca r cin o m a . fel i nepol ycysti ki
di agnosi s: c dneydi sease.

Figurc 42-8. of a caninekidneywith a mass (m)
Sagittalultrasonogram
degeneration, but its relevancein the assessmentof clinically rele-
vant diseaseis questionable. Diffuse parenchymal diseasepresents
more of an interpretive challenge. In these patients, the renal
architecture may not be disrupted, but the renal echotexture may
be abnormal (e.g.,greaterthan the spleen)(Fig. 42-10). Biopsy or
fine-needle aspiration can be expedited using ultrasonographic
guidance and the margin of safetyimproves as well. This is particu-
larly problematic in cats due to the normal benign fat infiltration
that occurs which affects the renal echogenicity.tsDoppler ultra-
sound techniques have been applied to the kidney in an effort to
measure resistanceto renal parenchymal blood flow Although not
specific, increased renal blood flow resistance is associatedwith
both parenchymaland collectingsystemdisease.To'tt
Location, Kidneys may maintain relatively normal function
while being abnormally located. In animals and humans, ectopic
kidneys have been identified in the thorax, intra-abdominal region
(not the normal retroperitoneal space), and pelvic canal.3'76-78
Excretory urography and ultrasonography are useful in confirming
these unusually located masses as kidneys; excretory urography
may aid in the assessmentof the functional potential.
In addition to an ectopic kidney, a kidney may be displaced by
an adjacent mass.3In particular, adrenal massesmay displaceeither
kidney caudally; the right kidney may be displaced caudally by a
liver mass, and the left kidney may be displaced caudally by a mass
in the proximal extremity of the spleen. This indirect method of
assessingabdominal massesby adjacent organ displacement may
be used as an aid in establishing the differential diagnosis.
Radiopacity. On survey radiographs, variations in renal radio-
pacity (from the expected soft-tissue appearance) are recognized.
The most common opacities recognized include air or mineral. Air
Figure 42-9. Transverseultrasonogramof a canine kidney at the level oi
the renalsinus.Note the dilatedrenalpelvis(p)typicalof hydronephrosis
The Kidneysand Ureters 561
Figure 42-1O- Sagittal
ultrasonogramof a caninekidneywhereinthe renal
cortices
areas echogenic
as the spleen{s).Notehowbrightthe renalcortex
appears,(Compareto Fig.42-3.)Interpretation: renaldiseaseor
infiltrative
acutetubular
necrosls.
may result from vesicoureteralreflux from previous pneumocystog-
raphy, but it may also be the result of trauma to the perirenal area
with leakage of air from intraperitoneal or extra-abdominal
sources.Mineral radiopacity may be due to the presenceof renal
calculi (Fig. 42-ll), which are usually magnesium ammonium
phosphatein both dogs and cats.3,7e Other chemicaltlpes of calculi
may be encounteredwith some frequency; however,the radiopacity
may vary with the degree of mineralization and is not specific for
chemical composition of the calculus. Other mineral opacities
within the kidney that must be considered include mineralized
cyst,3calcified tumors,3 calcification of the renal parenchyma
(nephrocalcinosis),3'7e and osseousmetaplasiaof the renal pelvis in
the presenceof renal disease.82'83 As previouslymentioned, loss of
retroperitoneal contrast due to emaciation, the presence of peri-
renal (retroperitoneal)fluids (i.e., blood or urine), or both, may
impede or preclude visualization of the kidneys. The determination
of the need for immediate excretory urography or sonography
must be made on the basis of the assessment of the remainder of
the body fat stores as well as the clinical history.
Excretory urography causesan increasein the radiographic opac-
ity of the renal parenchyma through the accumulation of contrast
medium within the renal tubules and vasculature. The opacity of
the renal outflow tract is also increased because of urine that
contains concentrated contrast medium. The identifiable structural
alterations of both the nephrograma and the pyelogramn are de-
scribed in Tables42-3 and 42-4, respectively;Figures 42-4 through
42-7 and Figure 42-ll provide examples of structural nephro-
graphic alteration. Figures 42-12 and, 42-13 are examples of two
common causesthat result in structural alteration of the pyelo-
gram. The use of Tables 42-3 and 42-4 in the separateevaluation
of the nephrographic and pyelographic architectuie is suggestedas
a beginning, and common diagnoses (if any occur in both gamut
lists) should then be pursued.
Function. The alterations in nephrographic opacification and
fading sequencesare described in detail in Table 42-5. ln general,
these changesare classifiedaccording to the degreeof opacification
encountered on the immediate postinjection radiograph, as well as
the relationship of the subsequently encountered nephrographic
opacity in the patient in comparison with the initial opacification.a,'zO
Differential considerations for each of the nephrographic opacifi-
cation sequencesare listed, but those listed are not the only possi-
bilities. Early first (10 to 30 seconds)nephrographicopacification
may be delayed in animals with acute and subacute pyelonephri-
tis.8a'8sFigure 42-14 rs an example of an abnormal nephrographic
opacity sequence(comparewith Fig. 42-1).
The most common alteration of the pyelographic phase of the
excretory urogram is poor or undetectable opacification of the
pyelogram. The opacity of the pyelogram is dependent on both
562 A N IMA L S
A B DO M E N-C O MP AN IO N

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

Table 424. Pyelographic appealance of some common

diseases of the kidney
Table 42-5. Possible nephrographic opacification
Pyelonephritis sequences associated with certain renal disease
Acute proGesses
Pelvicdilation
Good initial opacificationfollowed by progressivelydecreasing
Proximal ureteraldilation
opacrry:
Absent or incompletefilling of pelvic recesses
Normal
Chronic
+ Pelvicdila tionwith ir r egularbor der s Fair to good initial opacificationfollowed by progressively
increasingopacity:
Proximal ureteraldilation
Systemichypotensiondue to contrastagents
Short blunt oelvic recesses
Acute renal obstruction(includingprecipitatedTamm-Horsfall
Hydronephrosis m u c o p r o t e i ni n r e n a lt u b u l e s )
Pelvicdilation C o n t r a s tm e d i u m - i n d u c e dr e n a lf a i l u r e
Dilationof pelvic recesses(Nofe: recessesmay not be
Fair to good initial opacificationfollowed by persistentopacity:
distin gu ish ab leif pelv ic dilat ion is s ev er e)
A c u t e r e n a lt u b u l a r n e c r o s i s
Ure te raldila tion
C o n t r a s tm e d i u m - i n d u c e dr e n a l f a i l u r e
Neoplasia Systemichypotensiondue to contrastagents
Renal parenchyma
Poor initial opacificationfollowed by progressivelydecreasing
Distortionor deviationof renal pelvis,with dilation
opacrry:
Distortionor deviationof pelvic recesses
P r i m a r yp o l y u r i c r e n a lf a i l u r e
Renal pelvis
I n a d e q u a t ec o n t r a s tm e d i u m d o s e
Distortionor dilation of renal pelvis
F illin gde fectsin ren al pelv is Poor initial opacificationfollowed by progressivelyincreasing
opacity:
Uroliths and blood clots
Acute extrarenalobstrucrron
F illin gde fectsin ren al pelv is
Systemichypotensionexisting before contrastmedium
Uro lith susua llyra dio luc entc om par edwit h c ont r as tm e d i u m ;
administration
blood clots always are radiolucentcomparedwith contrast
R e n a li s c h e m i a( a r t e r i a ol r venous)
me diu m
May b e cha ng esa s seen in py elonephr it is Poor initial opacificationfollowed by persistentopacity:
+ Pelvicdila tion P r i m a r yg l o m e r u l a rd y s f u n c t i o n( c h r o n i c )
Severegeneralizedrenal disease
From Feeney DA, Barber DL, Osborne CA: Advances in canine excretory
urography. ln 30th Gaines Veterinary Symposium, 1981. White Plains, From Feeney D A , B arber D L, Osborne C A : Functi onal a s pec ts of the
Gaines Dog Research Center. nephrogram in excretory urography: A review. Vet Radiol 23:42, 1982.
 The KidneVsand Ureters 563

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 42-12. Ventrodorsal view 40 minutesafter intravenouscontrastmedium injectionfor

excretoryurography.The right ureter,renal pelvis,and pelvic recessesare symmetricallVen-
larged.The left kidneyis dramaticallyenlarged,with only a rim of nephrographicopacification,
The central portion of the left kidney is nonopacified,and there is no pyelogram,Necropsy
confirmedmoderateright and extreme left hydronephrosis secondaryto ureteralobstructionby
a transitionalcell carcinomaof the bladdertrigoneand proximalurethra,

Figure 42-13. Ventrodorsalview 20 minutes after intravenousinjection of

contrast medium for excretory urography.The right and left renal pelves are
dilated,but the pelvic recessescannot be identified.The ureters,particularlythe
diagnosis:bilateralchronicpyelonephritis.
right ureter,are mildlydilated.Radiologic
 The Kidnevsand Ureters 565

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 .

Figurc 42-17. Lateralview of a retrograde,posjtivecontrastvaginogramin a

bitch with an ectopicureter/ureterocele. The ectopicureter(u) is dilatedand ends
in a ureterocele(uc). (Reprintedwith permissionfrom Johnson GP: Contrast
v a g i n o g r a p hi yn t h e b itch :T e ch n iq u eas n d a p p lica tio n s.
Pr o ceedi ngs
319: R epro-
ductionand Paediatrics. Post GraduateFoundationin VeterinaryScience,February,
1999, Universityof Sydney.)
568 A N IMA L S
A B DO M E N- C OMP AN IO N
ary to intraluminal infection, periureteral inflammation, trauma,
or ureteral obstruction (see Figs. 42-12 and 42-15).4'6'85'86'e2'e3
Differentiation among these possible causesrequires complete as-
sessment of the size, shape, and margination of the opacified
ureter as well as observation of the site and character of ureteral
termination. Comparison with the results of urine rytologic and
culture studies is also of value.
Vesicoureteral reflux is the retrograde flow of urine from the
bladder into the ureter either as a low-pressurephenomenon in
the presence of incompletely filled bladder or as a high-pressure
phenomenon in the presenceof a filled bladder or during voiding.nu
Vesicoureteralreflux may be encountered in immature small ani-
mals and may be induced during retrograde radiographic proce-
dures. Reflux may also be induced secondary to manual compres-
sion of the urinary bladder in an attempt to perform voiding
Figure 42*18, A, Lateralview of a patient in which there are
mul ti pl ecysti ccal cul i but
, there i s al so an i ncreasei n opa c i tyand
loss of detailin the retroperitoneal space.Intra-abdominal contrastis
also poor. Latera (B) and ventrodorsal/C/ views 30 minutes after
intravenousinjectionof contrast medium for excretoryurography
revealpromi nentdi sconti nui ty of the ri ghtureterw i th extra v as ati on
of contrastmedi umi ntothe retroperi toneal space.R adi ol og di
i c agno-
sis: rupturedright ureter.
urethrography. The major significance of vesicoureteral reflux lies
in the potential of retrograde flow of urine contaminated with
pathologic organisms from the urinary bladder toward the kidney.
The normal ureter is not visible sonographically as a tubular
entity except as it enters the urinary bladder.'qt3,14,23' 2s This is
most easily recognizedby the characteristic "flow jet" produced in
the bladder lumen when the peristaltic ureter ejectsurine. However,
when the ureter is either focally or diffusely enlarged, it can be
recognized as a fluid-containing tube that may or may not have
evidence of peristalsis during real-time ultrasonography. As the
ureter exits the kidney, it can create a circular black void in the
otherwise uniformly bright renal sinus fat in the renal hilus when
viewed in the sagittal plane. The dilated renal pelvis can be seen to
make a "funnel-shaped" transition into a dilated ureter at the
ureteropelvic junction when viewed on the transverseplane
 The Kidneysand Ureters 569

through the renal hiius. On occasion,it is possible to

trace the 29. Senior DF: parasites of,the urinary
tract. In Kirk RW (ed): Current Veterinary
dilated ureter along its retroperitoneal path uiing .,lt.urorrog."phy. Therapy VII. philadelphia, WB Saunders,
1980.
However, the-technique of excretoryurographlproviaes
a"better 30. Barsanti JA, Crowell R: Renal amyloidosis.
In Kirk RW (ed): Current Veterinary
arsessmentof ipsilateral renal function/conientrating Therapy VII. philadelphia, WB Saundeis,
ability and 1980.
the ureteral peristaltic capability than does ultrasonography.
31. Brace JJ: perirenal cvsts. (pseudocysts)
in the cat. In Kirk RW (ed): Current
Veterinary Therapy Vl. lhiladeghia, '
ffi;;;rr, iiso."'
References
,?r,^l,o1l!* JL: Congenital solitary renal cyst in a dog. Am
ll:199. 1975. I Anim Hosp Assoc
l. DiBartola SP: Clinical approach and laboratory
evaluation of renal disease. In
Ettinger SJ (ed): Textbook of VeterinarF lnternal Mehicine, 33. Calvood DD, Osborne CA,
4th ed. philadelphia, WB iohnston GR; Neoplasms of the canine and feline
S a un d e rs,1 9 9 5 . Kirk RW (ed): current Veterinary Therapf
::]1"11 ]ti.^,::r"
Jaunders, vtr. lhitud.tphi", wn
2. Osborne CA, polzin DJ, Feeney DA, et al: The urinary 1990.
system: pathophysiology,
diagnosis,.and therapy. In Gourley IA, Vasseur pB
i.JJ),-t"n.r"l Small Animal .1-1-Y:5:,1"",.t9:9urryt.. JL: polycystic disease of the kidney and liver in the
Surgery. Philadelphia, JB Lipprncott, i985. canme teriler. Vet pathol 17:436,19g0.
3. Allan G: Radiology in the diagnosis of kidney disease. 35. Lulich IR Osborne ao: *."1,,:.
Aust Vet pract I2ig7, 1982. al; Feline idiopathic polycystic kidney
disease.Comp Contin Educ pract Vet ^pA,.et
4. Feeney DA, Barber DL, Osborne CA: Atlvances in Small e"i- fo,ib:0, li8s.
canine excrerory urography.
In Proceedingsofthe 30th caines VeterinarySymposiun, 36. Rendano VT, parker RB: polycystic
t98i, GainesOog n!r""..,h kidneys and peritoneal pericardial diaphrag_
C e n te n Wh i re P l a i n ., N y, p 8. matic hernia in a cat. J Small Anim pract
tZ:+)g, nZi.
5. FeeneyDA, Barber DL, Iohnsro.nGR, et al: The excretory .lbchniques, Crowell WA, Hubbell IL Riley polycystic
urogram; _37._ JC: renal cliseasern related cats. I Am
normal radiographicappearance,and misinterpretation. Vet Med Assoc 175:286,1979.
comp contin Educ pract vet
41233,1982.
38. Osborne CA, Iohnston KH,^Kurtz
Hl, et al: Renal lymphona m the dog and cat.
6. Kneller SK: Role of excretory urography in the
diagnosis oi renal and ureteral J Am Vet Med Assoc 158:2058,1971.
disease.Vet Clin North Am 4;843, 1974,
Barbo DL: Radiographic evaluation
of a focal inflammatory renal lesion. Am
7. Feeney DA, Thrall DE, Barber DL, et al; Normal Anr
^39.m H os p As s oc I2:451, 1976. J
canine excrerory urogram:
Effects of dose, time and individual dog variation. Ar"
I V"t n"s 4O:1596,t9./9. phaneuf
JB,^OliverN, et al: Glomerular polycystickidney disease
,10. thal{ou1,
r n a dog.
8. FeeneyDA, Osborne CA, JessenCR: Effectsof radiographrc C r n Vc l I 2J :J 65,19g2.
_ contrast media on
of the urinalysis with emphasis on specific grn"uiry. 41. Bernard MA, Valli VF.: Familial
11._:ir-"]tr .y A,o Vet Med Assoc renal diseasein Samoyed dogs. Can Vet
176:1378,t980. J
l 8:181, te77.
9. Ruby AL, Ling GV, Ackerman N: Effects of sodium 42 Brown cA, croweil wA, Brown
diatrizoate on the in yitro sA, et al: Suspected familiar renal disease in
growth of 3 common canine urinary bacterial species.
Vet Raiol 24:222, 1983. Chow Clrows.J Am Vet Med Assoc 196:1279,1990.
10. FeeneyDA, Johnston GR, Walter pA: Imaging 43. Casal ML, Giger y. Bovee KC, paterson
the kidney and prostategland in
small-animals;Has gray-scaleultrasonography"reilaced DF: lnheritance of cystinuria and renal
contiast radiographi? lrobl defect in NewfounJlands. Am Vet
Ve t Me d 3 :6 1 9 ,1 9 9 1 . J Mecl Assoc,o?ri*;l;;;.
14. Chew DJ, DiBartola SR Boyce
ll: Kgl9. Ll, Wigley RH, park RD, Lebel IT, et ai: Juvenile renal diseasein Doberman
/L: Ultrasound anatomy of the normal Pinscherdogs. I Am Vet Med Assoc
canine kidney. Vet Radiol 21173, 1984. 182:481,19S3.
45. Cook SM, Dean DF, Golden DL,
12. Walter PA,, Feeney DA, .fohnston GR, Fletcher et al: Renal failure attributable to atrophic
TF: The norrral feline renal glonrerulopathyin fbur reratedRottweilers.
utrrasonogranl:euantitatjve analysisof intagedanatomy. r A'" t;; M;;# 202:107,1993.
Am J Vet Res4g:596,19g7.
46. Davenport DJ, DiBartola SB Chew
DJ: Familial renal diseasein the dog and cat.
13- PA, Johnston GR, Feeney DA, O,Brien TD: Renal Cont IssuesSmall Anim pract 4:137, 19g6.
. -Walter ultrasonographyin
healthy cats.Am J Vet Res48:600,1987.
47.,DiBartola SB Chew Dj, Boyce
14. Wood AKW_ _McCarthypH: Ultrasonographic_anatomic lT: fuvenile renal diseasein related standard
correlation an<l an im_ poodles.J Am Vet Med Assoc 183:693,
1983.
aging protocol of the normal canine kidney. Am Vet
J Res 5l:103, 1990.
DiBartola-Sp,Tarr M[, Webb DM, Giger
.48. U: Familial renal amyloidosisin Chinese
15. YaegerAE, Anderson WI: Study of association Shar Pei dogs. I Am Vet Med Assoc lg7:48J,
between histologic featuresand 1990.
echogenicityof architecturallynormal cat kidneys.Am
I V.t n r-SO,SOO, fSSS. 49. EnglishPB, Winter H: Renalcortical
hypoplasiain a dog. Aust Vet 55:181,1979.
16. Finco DR, Stiles NS, Knells-SK, et al: Radiologlc J
estimation of kidney size in
the dog. J Am Vet Med Assoc 159:995,1971. K, Grondalen l: Fanilial renal diseasein
^50.,,Eriksen Soft_coatedWheaten Terriers. J
Small Anim Pract 25:489,I984.
1 7 . Ba rre tt R B , K n e l l e r SL: Feline kidney measur ation.
Acta Radiol ( Stoc k h) 51. Felkai C, Voros K, Vrabley T, et al:
319(suppl):279, 1972. Ultrasonographic findings of renal dysplasia
in Cocker Spaniels: Eight .ur.r. A.tu Vet
Hung sS,:61,'tgii'."-"'
18. BartelsJE: Feline intravenousurography. Am Anim
J Hosp Assoc 9:349,1973.
and inherited renal disease. Am Anim
19. Shiroma jT, Gabriel JK, Carter TL, et al: Effect nlr';,1,};"r.o*'congenital I Hosp Assoc
of reproductive status on feline
renal size. Vet Radiol Ultrasound 40:242,1999-
53. Finco DR, Kurtz HL Low DG, et
al: Familial renal disease in Norwegian Elk_
20. FeeneyDA, Barber DL, Osborne-CA: Functional hound dogs.J An Vet Med Assoc t5(t:747,1970.
aspectsof the nephrogram in
excretory urography: A review. Vet Radiol 23:42, 1982.
54. Io3e: BR, Cething MA, Badcoe LM,
et al: Familial progressive nephropathy in
21. Thrall DE, Finco DR; Canine excretory urography: young Bull Terriers. N Z Vet 37i79, 1989.
Is quality a function of BUN? I
J Am Anim Hosp Assoc 12:446,1976.
55. Jones BR, Jones JM, Chen W, Cayzer
J: Chronic renal failure in young Old
22. Forrest LJ, O'Brien RT, Tremelling MS, et al: Sonographic English Sheepdogs.N Z Vet j 38:118,1990.
renal findings in 20
dogs with Leptospirosis.Vet Radiol Ultr;sound 39:337,
D:g8,. VanWinkie TJ: Renal dysplasia in Golden
.il;rf.l,l:^oa, Retrievers. Vet pathol
23. Konde LJ: Sonographyof the kidney. Vet Clin North
Am l5:1t49, 1985.
24. Mantis R Lamb CR: Most dogs with medullary U, Neumann F, Trainin R: Renal cortical
rim sign on ultrasonography _.57'-|l9qfer hypoplasia rn a Keesond litter.
have no demonstrable renal dysfunciion. Vet Radiol titt.urorr"J-ai,ro+, Vet Med Snall Anim Clin 70:1081, 1975.
zOOo.
25. Walter PA, lohnston GR, Feeney DA, et al: Applications Keman JP,Bicwenga wl, Gruys E; proteinuria
of ultrasonography in -58. glomerular collagen associatedwith glomerulosclerosis
the diagnosis of parenchymar kid."y dir.ur. i" .utr. and fornation in 3 Newfoundlana aog iiii.r-ut*.
i i- v"t rral Assoc 192:92, 1988. 31:188,1984. Vet pathol
26. Cq?ers MD, crooters AM, Willims
l, partington Bp: Renomegaly in dogs and 59. Lees GE, Helman RG, Homco LD,
cats:Differential diagnosis.Comp Contin Educ prac-Vet el al: Early diagnosis of familial nephropathy
19:1019,i997. in English Cockcr Spaniels. Am Anim
J Hosp Assoc:+,iSS, f9%.-
27. Robinson GW: Uterus unicornus and unilateral
renal agensrs.J Am Vet Med 60. Lucke VM, Kelly DF, Darke pG, et
A s s o c1 47 :5 1 6 ,1 9 6 5 . al: Chronic renal failure in young dogs:
Possiblerenal dysplasia.I Small Anrm pract
21:169,1980.
P, Carrig CB, Walshaw R: Renal and ureteral duplication
.28..O'Handley in a dog. I Mason NJ, Dan MJ; Renal amyloidosis
Am Ve t Me d A s:o c 1 7 4 :4 8 4 1
, 979 .61. in related English Foxhounds. J Small
Anrm Pract 37:255, 1996.

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-
drome in Basenjis in the United States.J Am Vet Med Assoc \97:345,1990'
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
1 80 :6 5 8 1
, 982.
97. Ross LA, Lamb CR: Reduction of hydronephrosis and hydroureter associated
with ectopic ureters in two dogs after ureterovesicalanastomosis.J Am Vet Med Assoc
196:1497,1990.
98. Scott CW Greene RW, Patnaik AK: Unilateral ureterocele associatedwith hydro-
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.

70. Witcock BR Patterson JM: Familial glomerulosclerosis in Doberman Pinscher

dogs. Can Yet I 20t244, 1979'

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
12:139,1975.
93. Rose IG, Gillenwater lY Effects of obstruction and infection upon ureteral
function. Invest Urol 11:471,1974.
94. Burton CA, Day MJ, Hotston-Moore A, Holt PE: Ureteric fibroepithelial pollps
in 2 dogs. J Small Animal Pract 35:593, 1994.
6. Unilateral failure of (or unilateral delay in) renal parenchymal
opacification during an excretory urogram may be causedby which
of the following?
A. Poor renal function (e.g., chronic renal diseasewith azote-
mia)
B. Inadequate dose of radiographic contrast medium
 The UrinaryBladder 571

C. Poor systemic blood pressure due to contrast medium_

E. All of the above
induced hypotensron
D. Ureteral obstruction
9. An enlarged, but smooth.and,proportionally
E. All of the above shaped,kidney
can be the result of which of the foliowing
*fr." '"i.*.a by s,rrlr.y
radiography?
7. Which of the following should be considered if there is unilat_
A. Hydronephrosis
eral, proportional dilation of the renal pelvis, pelvic recesses,and
B. Infiltrative renal disease (e.g., feline infectious
ureter during an excretory urogram? peritonitis,
amyloidosis)
A. Pyelonephritis
C. Compensatory hypertrophy
B. Hydronephrosis
D. AandB
C. Primary renal parenchymal neoplasia with invasion of the
E. A, B, and C
collecting system
D. All of the above
10. Which of the following can cause diffuse,
E. None of the above unilateral ureteral
dilation when viewed dur'lng an excretory urogram?
A. Ectopic ureter
8. If the. observed nephro.graphic opacity is initially bright, but
B. Urinary bladder mass causing obstruction
persists with similar intensity on thJ films made in an excretory of one ureter at
the trigone
urographic series,which of the following should be considered?
C. Ascending pyelonephritis
A. Normal occurrence
D. AandB
B. Glomerular dysfunction
E. A, B, and C
C. Dehydration
D. Acute extrarenal obstruction
Answers begin on page727.

CHA P T E R

43
The Urinary Bladder
I Richard D. Park r Robert H. Wrislev

f Normal anatomy holding food for 24 hoursbeforethe study,giving

enemasto clear
-c'a"udaily
The urinary bladder is divided grossly into three parts: the vertex and pulling the p.t"i. ii-i, when the
ll:,lT.,bowel,
raolograph rs made.
(apex.vesicae)cranially, the body (corpus vesicaejin
the middle,
and the neck (cervix vesicae)caudally (Fig. 43-l).rr Three liga_ Bladder size varies with the amount of
urine in the bladder.
ments formed from peritoneal reflections hotd ttre Uhaaer loo#ly After the. patient voids, the bladder ir .-"ii'-"r''ir
not visible
in position.3 The middle bladder ligament (ligamentum vesicae radiographically. with extreme distention,
the .ra.riar bladder bor-
medianum) extends along the ventral bladder surface, and two
lateral ligaments (ligamenta vesicaelateralia) extend along the lat_
eral bladder surfaces.Theseligaments often contain large fit depos_
its' facilitating radiographic visualization of the bradder neck and
body.The cranial and dorsalsurfacesofthe bladderare radiograph_
ically visible because of adjacent fat within the omentum and
mesentery (Fig. a3-Z).
The urinary bladder wall is a musculomembranous structure
consistingof mucosal,submucosal,and muscularlayers;the perito_
neum is-closely adherent to the serosalsurface,p.orridirrg a separate
fourth layer. Neither the thickness of the bladder wall nor the
mucosal surface of the bladder can be assessedon survey radio_
graphs.because the adjacenturine has the sameradiographicopac_
ity as the bladder wall.
Radiographic visualization of the urinary bladder is compro_
mised by insufficient abdominal fat, inadequate distention, and
superim-position opacities. or young animals may not
have sufficient abdominal fat -Emaciated
to provide good tlssue contrast adja_
cent to the urinary bladder. Ingested maierial in the small bowel,
fecal material in jhe large bowel, muscle tissue from the pelvic
IrmDs, and bone from the spine and pelvis cause superimpoiition
opacities that may obscure all or pirt of the urinary tludd... Figure 43-1. Diagramof a lateralvjew
of the abdomenIn a normal male
Focal.superimposition opacities 6e createdby fluid_filled small dog-.a, vertex; b, body of the_btadder;.,
.l.i?ir" urinary btadder;d,
Dowel, nlpples, prepuce, and cutaneous
-ay masses.Some of these lj-":l:]^:," "lq
e,
.larse
bowet. rhe-broken t , u.rnj-il'" urinary bladder
superimposition opacities can be eliminated or minimized by with_ the.penroneatreftecrion
aroundand adheientto rhe serosal
:::?::t
surraceot :?p,:t.".lts
the urinarybladder.
572 A N IMA L S
A B DO M E N- C OMP AN IO N

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
superimposed (longarrows)overthe cranialanddorsalborders of the bladder' may be identified by cystography or ultraosonography. Bladder
der may extend to the umbilicus. Severedistention may occur in a
normal bladder if the animal has not had an opportunity to void
or will not void because of a strange or unfamiliar environment.
The urinary bladder in the dog is usually oval, but with distention
it becomesmore ellipsoid (Fig. a3-3A). The feline urinary bladder
is almost always ellipsoid (see Fig. 43-38).
The bladder is cranial to the pubis, dorsal to the rectus abdomi-
nis muscle, caudal to the small bowel and omentum, and ventral
to the large bowel. In females, the uterus lies between the bladder
and the rectum. The normal urinary bladder may be partially
within the pelvic canal or cranial to the pubis (external to the
pelvic canal).a'sThe distendedurinary bladder is more often lo-
cated cranial to the pubis but may be within the pelvic canal'n''
The normal urinary bladder in the cat is always intra-abdominal
and is located 2 or 3 cm cranial to the pubis. This positioning
results from the long bladder neck in the cat,6which is not always
visible on survey radiographs.
The urinary bladder is a soft-tissue opaque structure' Any opac-
ity greater or less than that of soft tissue detected within the
bladder on surveyradiographsis abnormal.
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.
hernias, the bladder may not be seen on survey radiographs but
retroflexion was found on examination in 12 (20o/o)of 61 dogs
with a perineal hernia.8 A urinary bladder partially within the
pelvic canal (Fig. a3-6) may be associatedwith congenital urinary
tract anomalies.' A minimally distended bladder may be pelvic in
position and displaced more cranially when distended; pelvic blad-
ders have been reported as a normal variation.a's Incontinent
female dogs with a pelvic bladder usually have shorter urethras
than do continent dogs.lo Becausepelvic bladders do not always
indicate a clinical problem, a pelvic bladder should be coordinated
with clinical signs and tests to determine its clinical significance.
It is uncommon to observe a change in shape of the urinary
bladder on survey radiographs. Abdominal masses adjacent to
the serosal surface of the bladder may distort the bladder shape.
Occasionally, tumors originating from the bladder wall protrude
from the serosal surface and produce a discernible change in
bladder shape (Fig. 43-7).tt A pointed vertex with the bladder
appearing elongated may occur with a persistent urachal ligament
in the cat.t'?
An abnormally small or large urinary bladder is difficult to
diagnose radiographically becauseof the wide normal variation in
bladder size.In most instances,a consistentlysmall or large bladder
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

Table 43-l- Urinary bladder: survey radiographic signs

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

Figure 434. Lateralradiographof the abdomenof a cat. The kid_

neys are eastlyseen (arrows).The serosalsurfaceson the bower and
urinarybladderdo not have distinct outlines becauseof free perito_
nealf l u i d .
574 AN IM AL S
A B DO M E N -C O MP AN IO N

Figurc 43-5. Positive-contrast cystogram,lateralcaudalview, in a

mal e dog. The uri narybl adder(a)i s di spl acedcrani al ly
from the pubi s
by a large prostaticmass.The urethraand bladderneck are filled with
positive-contrastmedium {affowsl.Diagnosis:prostaticcarcinoma.

Figure 43-6. Lateralradiographof the caudalabdomenand pelvis

after intravenousurographyand double-contrast cystography.A radio-
oao u ec a t h e t e irs p r e s en with
t r p arti al l y
inth e b la d d e ra, n dth e b la d d eis
within the pelviccanal (arrows).Contrastmedium has accumulatedin
the vaginaia) becauseof an ectopicureter.

Figurc 43-7. Oblique view of the abdomen after double-contrast

cystography.A mass /smal/ arrows) is present on the cranloventral
aspectof the gas{illed bladder(largearrowd. fhe mass is a leiomyo-
sarcoma originatingfrom the bladder;it gave the bladdera bilobed
appearanceon the surveyradiograph.

Figure 43-8. Lateralview of the abdomenof a dog with gas within
the bladderwall and lumen (arrows).Gas in the surroundingbowel
lo o p sp r e s e n t ss o m e d ifficu ltyin d istin g u ish ingga s with inth e bl adder.
T h e a n i m a lh a dc y s t i t isca u se db y a g a s- p r o d u cinogr g a n ism .
(Table43-2), however,and thus the absenceofradiopacitieswithin
the bladder does not rule out the presenceof cystic calculi. A
horizontal-beam radiograph can be made to diagnose sandlike
materiai within the bladder. This is particulariy helpfui in cats with
feline urologic syndrome.'t
I Contrast cystography
Retrograde contrast cystography is a fast, simple, and inexpensive
technique that may provide valuable prognostic and diagnostic
information about bladder disease.Clinical indications justifiing
cystographyinclude dysuria,pollakiuria,and intermittent or persis-
tent chronic hematuria.Radiographicsignsthat justifu cystography
include identilication of increasedor decreasedopacity that may be
associated with the urinary bladder,evaluationof caudalabdominai
massesthat may be associatedwith the urinary bladder, nonvisual-
ization of the bladder after abdominal trauma, and evaluation of
the urinary bladder with an abnormal shapeor location.
Voiding cystographyis not discussedin this chapter.For more
information, the reader is referredto other publications.l8t2Void-
ing cystography, coupled with cystometry and urethral pressure
profiles, is the technique of choice for investigating dynamic blad-
der diseases such as urinary incontinenceand other voiding abnor-
malities.
Cystography technique
If possible,food should be withheld for 24 hours and an enema
given before a cystographic examination is begun. Fecal material
superimposed over the urinary bladder may obliterate important
radiographic information.
Table 43-2. Radiopacity of cystic calculi on survey
abdominal radiographs
Calculus composition
Opacity
Calciumoxalate Radiopaque
S ilica Radiopaque
Triple phosphate Radiopaque- s m allc alc u l im a y b e
nonr adiopaque
Cystine Nonr adiopaque,but m ay h a v e
r adiopaques t ippling
U rate Nonr adiopaque
,$l$
The U ri naryBladder 575
All cathetersand equipment should be sterilized,and the genita-
lia should be cleanedbefore the bladder is catheterized.The equip-
ment necessaryfor bladder catheterization is illustrated in Figure
43-9. To reduce bladder pain and spasm during cystography, 2 to
5 mL of 2% lidocaine (Xylocaine) without epinephrine may be
injected into the bladder before cystographyis performed.
Complications resulting from catheterizationand cystographic
proceduresoccur infrequently and are usually not detrimental to
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
kinked'z*and knotted urethral cathetersmay occur from improper
catheterizationtechniques.Intramural and subserosalaccumulation
of contrast medium in the bladder (Fig. 43*10) has been reported
after maximal bladder distention with a Foley catheter.25-r8 This
complication occurs more frequently in the cat. often with a non-
distendedbladder and minimal intravesicularDressure.It usuallv
does not result in a clinicalproblem. Mucosalulceration,inflam'-
mation, and granulomatous reactions may occur, but the changes
are usuallytransitoryand produceno seriousclinicalproblemi.r"
The most seriouscomplication from negative-contrastcystography
is gas embolization into the circulatory system, which may result
in death.3o 3'?Fortunately, such complications
occur rarely. Also,
death from gas embolism may be prevented by the use of nitrous
oxide or carbondioxideinsteadof room air.
_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
20o/oiodine solution (Table 43-3). Barium shou'id never be used
for cystography.2s' 33The volume of positive-contrastmedium used
for cystography varies with body weight, the species, and the
pathologic processpresent in the bladder. An approximation of 10
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
around the catheteE or if back pressure is felt on the syringe
plunger. Moderate bladder distention is recommended as complete
distention may obliterate subtle mucosal and bladder wall
changes.3a Four radiographic views of the caudal abdomen (one
recumbent lateral, one ventrodorsal,and two recumbent oblique)
should be made to adequatelv examine the contrast medium-
llled bladder.
Cystographic procedures
Retrogradepositive- and double-contrastproceduresare best for
study of the bladder. Positive-contrastcystography is performed by
I'7 6 AN IM AL S
A B DO M E N -C OMP AN IO N

Figurc 43-9, Equipmentfor bladdercatheterization and

cystography. A, Tom Catcatheter;B, Male urethralcatheter;
C, a largesyringe;D, A Foley(balloon-type) catheter;E A
three-wayvalve;and t A catheterconnectorfor use with
the male urethralcatheter.(FromParkRD: Radiologyof the
uri narybl adderand urethra.In O'B ri enTR [ed]:R adi ographi c
D i agnosi sof A bdomi nalD i sordersi n the D og and C at.
Davis,CA, CovellParkVeterinaryCompany,1981.)

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

Figure 43-1O. Positive-/A/ and double-contrast/B/ cystogramsin which subserosal

pro d u c e sn o s e v e r eo r lo n g - la stinco accumulationof contrast meorum may be seen (arrowsl.
g m p lica tio n s.
It is p r o d u c edby a hi gh i ntral umi nal This usuallv
bl adderpressureand rs predi sposed
by bl adderdi seas e,parti c ul arl v
I nll a m m a t l o n .

with positive-contrastmedium. The size, shape,number, border Filling^.defecls

contour, position within the bladder,and attachmentto the bladder
wall should be examined with all bladder filling defects.Observing
these filling defect characteristics helps one io differentiate th!
nature of the-filling defect, which ultimately may prove helpful in
the processof reachinga diagnosis(Tablea3-5).' -
rttr9
Figure 43-11. Obliqueradiographof a normaldouble_contrast
cystogram.
The urinarybladderwall (arrows)is clearlyseen.The contrast,,puddle,,in the
dependentportionof the bradder(a)and the contrastmedium-fiiledurethra(b)
are easilvidentified.
, be categorized as free or attached. Free
-may
rumrnal hillng defects may be causedby air bubbles,calculi, seba_
creousor.mucgus Plugs,3s or blood clots (Fig. 43-15). They are best
demonstrated with double-contrast cystographyand
are seen
within the dependent contrast puddle, *fri.i i, in
the center of
the bladder on a recumbent lateial view. The concentration
of the
contrast medium and the depth of the contrast puddle
have an
effect on visualizationof cystic calculi of uaryi.rg composition.3T,3s
Attached filling defectsmay be causedby neopiasia
1fig. +:_te;,
inflammatory polyps, blood clots, iatrogenic he'matomas,
adherent
calculi, and ureteroceles(Fig. 43-17).ir"Mural masses
may be seen
only on views in which thi positive_contrast medium
gravitates
around the masswith double-contrast cystography.r0
Muco"salirreg_
ularity and ulcers are frequently present J., ihi ,r.rrf"..
of larie
attached-filling defects.Bladder wall infiltration may
be diagnosJd
as a thickenedbladderwall adjacentto the filling defect.a'Ali'hough
a,specific diagnosis cannot always be made fiom the
cystogralm
when attached filiing defects are present, the defectsmay
be differ_
entiated by surgical removal or Jtrasound_guided
biopiy.
Contrast extravasation patterns froi the uriniry
bladder.
Retrograde positive-contrast cystography best demonstrates
con_
trast medium extravasation from-thi urinary bladder.
Contrast
medium extravasationmay occur within the r'rrinu.y
tract, thereby
enabling communication with other visceral structures,
or within
the^peritoneal cavity and surrounding soft tissues.
Contrast medium extravasation fr-om the normal bladder
con_
fin^ed within the urinary tract may be seen with
vesicoureteral
rethx, urachal anomalies, and traumatic bladder diverticula (Fig.
43-i8). Congenital urachal anomalies include diverticula,azr.
cysti,
and perslstentpatent urachus.aHT
The contrast medium borders produced by extravasation
within
the urinary tract are usually smooth and may be identified
as
extensionslrom Lheurinary bladder.
Contrast extravasation from the urinary bladder to
adjacent
structures may be seen with either congenital or acquired
:1...:rul
hstulas. The organs most commonly involved aie the recturi
and
the vagina. The communicating segment may not be
outlined with
contrast medium in such a way as to be detected radiographically.
fistulas.can usually be diagnosed with fluoroscopf, or in
.Su;h an
rnclrect Iasnron on contrast cystograms;that is, the
structure that
communicates with the bladder fills simultaneously or shortly
after
the bladder is filled with contrast medium.
57A A N IMA L S
A B DO M E N-C OMP AN IO N

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.)

Table 434. Radiographic signs of pathologic procesaes of the bladder

Mucosal changes Intramural thickening Filling defect Contrast extravasation
Disease Attached Free Smooth lrregular
Chro n i c C r a n i ove n tr a l Occa sio n a l Cr a n io ve ntral Occasi onal B l ood cl ots B l ood cl ots
cystitis {cytoxan- C al cul i
i nduced
cystitis)
Poly p o i d C r a n i ove n tr a l Cr a nio ve n tral CranioventraI B l ood cl ots
cystitis
Acute cystitis Occasi onal
blood clots
Cystic calculi C r a n i ove n tr a l Cr a n io ve ntral C al cul iand
from from occasi onal
cystitis cystitis blood clots
Neop l a s i a Any location Occa sio n a l An ylo ca tion Occasi onal S essi l e, Blood clots
w i t h in with in occasi onal l y
b l a dd e r b la d d e r peduncul ated
Blad d e r A n y l o ca tio n L a r g ea r e a s Any location Large areas B l adderw al l Blood clots
contusron o f b la d d e r of bl adder hematoma
often often
in vo lve d involved
Blad d e r Blood clots Most
ru p t u r eo r extravasate
perforation i s i nto
peri toneal
cavity
Traumatic Blood clots A ny l ocati on
div e r t i c u l a
Urac h a l C r a n i ove n tr a l CranioventraI CranioventraI
div e r t i c u l a a s s o cia te o associated
with with
cystitis cystitis
 The UrinaryBladder 57||

Figure 43-13' A, oblique radiographof the bladderduringdouble-contrast cystography.Thereis mild mucosalirregularity

atongthe rightventral bladderprrows)
c a u s e db y c h r o n i cb a c te r iacystitis
l B, o b liq u er a d io g r a pohf t he bl adderduri ngdoubl e-contrast
cystography.
S evJremucosatrrregul ari ty
thickeningare presentalongthe ventralright bladder(arrows). and m i i d bl adderw al l

Figure 43-14. Lateralradiographof the urinarybladderfilled with positive-contrast medium

dur i n gi n t r a v e n o uusr o g r a p h y.
Diffu seb la d d ewa
r ll th icke n in g is presentas the resul tof C vtoxan-
rnducedcystrtis.The serosal surface (arrows)is outlined by fat. Bladderdistenslbiity is oe-
c re a s e db y t h e s e v e r ein tr a m u r ach
l a n g e s.On e u r e te ris d iste ndedas a resul tof obstructi on
at
t he u r e t e r o v e s i cjauln c tio n .
 A N IMA L S
5 8 O A B DO M E N- C OMP AN IO N

Tahle 43-5, Bladder-filling defects

Bladder wall infiltration
Lesion Shape Attachment Border/Contour (thickening)
Calculi Roundt o Free in lumen; center of Indistinct Variable;usually
slightly contrastpuddle cranioventralif associated
ir r egular with cystitis
Sebaceousor Round or Fr ee in l u m e n ; c e n t e ro f Smooth or irregular. Variable;associatedwith
muco us p lug ir r egular contrastpuddle distinct or indistinct cystitis
Polyp Pedunculatedor Stalk or sessile Smooth or irregular, V a r i a b l e ;b l a d d e rw a l l m a y
convex often with be thick at attachmentsite
ulceration
E pith e lialne op lasia lr r egularor Ses s ile lrregular,often with Bladderwall often thick or
convex u lceration infiltratedat base of
attachment
Mesenchymal Convex Sessile U s u a l l ys m o o t h Originateswithin the
neop lasia b l a d d e rw a l l
Blood clots lr r egular Variable;may be free l r r e g u l a ra n d Thickenedbladderwall
lum in a l i ndistinct from primary disease
Drocess
B ladde rwa ll Convex Sessile Smooth to slightly Originateswithin bladder
hematoma irregular wall
Ureterocele Convexto Sessile Smooth Originateswithin trigone
r ouno region of the bladderwall

Figwe 43-15. Free luminalfilling defects demonstratedwith double-con-

trast cystography.,4, Cysticcalculi,in the center of the contrast"puddle," are
round with an indistinctborder. B, Blood clots are irregularlyshaped with
irregular,indistinctborders;they may be locatedanywherein the bladder,C,
A i r bubbl esare roundw i th smooth,di sti nctborders;they are us ual l yon the
peri pheryof the contrastpuddl e,(From P ark R D : R adi ol ogyof the uri nary
bl adderand urethra.In O'B ri enTR [ed]:R adi ographiDci agnosi os f A bdomi nal
Disordersin the Dog and Cat. Davis, CA, Covell Park VeterinaryCompany,
1981.)
 The U ri narvBladder 581

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-
rounding soft tissueshas an irregulai outline and usually occurs
simultaneously with injection of contrast medium into the blad-
der (Fig. 43-19). With small bladder neck tears, extravasation of
contrast medium may be slow, with only a small volume extrava-
sated.6'a3
In theseinstances,a secondradiograph may be required
5 to l0 minutes after contrast medium injection to obtain
positive diagnosis.
Pitfalls with cystographic interpretation
Interpretation pitfalls are changes noted on the radiograph that
mimic actual pathologic changes.These changes ur. ariifu.ts that

Figure 43-17. Ventrodorsalradiographof the bladder filled with contrast medium

during intravenousurography.The smooth luminalfilling delect (arrows)thatprolectsinto
the bladderneck is a ureterocele.
5A2 AN IM AL S
A B DO M E N -C OMP AN IO N
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
. 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
are created during the cystographic procedure. Pitfalls commonly
seen with contrast cystography are air bubble artifacts and pseu-
dofilling defects.
There are three types of air bubble artifacts (Fig. 43-20): small
air bubblessimulating calculi or other small luminal filling defects,
a large air bubble simulating bladder wall thickening, and multiple
air bubbles creating a honeycomb appearance.Air bubbles are
radiolucentand have smooth distinct borders.
Pseudofillingdefectsmay be mistaken for bladder neoplasiaor
other attached filling defects. These defects are created by inade-
quate bladder distention combined with external pressurefrom
adjacentabdominal structures.Pseudofillingdefectshave a smooth
surfaceand taper on both borders (Fig. 3-21); they can be obliter-
ated with further bladder distention.
Figure 43-19, Positive-contrast cystogramin a cat. Contrastmedlum lills
the urinarybladder(a)but extravasatesinto the peritonealcavity(arrowil fhis
c om p l i c a t i ohna s r e s u l te dfr o m a te a r in th e b la d d e n
r e ck.
y trauma,traumati cdi verti cul must
a b e di fferenti ated
I Sonography
The fluid-filled urinary bladder is readily and easily evaluated
by sonography. The superficial location enables high-resolution
imaging, and the urine provides high sonographiccontrast,which
results in clear visualization of the bladder wall and intraluminal
abnormalities.Urolithiasis and neoplasiadue to transitional cell
carcinomaare readily and accuratelyshown by sonography.ae't0
High-resolution transducers(7 to 10 MHz) are best suited for
examinationof the bladder.A 5-MHz transducermay be necessary
to penetrate to the far wall of a distended bladder in large-breed
dogs. Linear and curved wide-aperture format transducers are
particularly useful. A standoff pad should be used with a sector
transducer to improve the image quality of the ventral bladder
wall. Image contrastsettingsshould be set to high-contrastdisplay;
acoustic power and near gain should be decreasedto suppress
reverberation echoes generated between the transducer, the skin,
and abdominal wall structures.
The sonographicexamination is best performed when the biad-
der is moderately full. A small bladder after recent urination is
more difficult to locate; the wall is thicker and image contrast is
reduced. Re-examination of the bladder should be done when
the bladder is moderately distended after some hours of inside
confinement, after administration of a diuretic, or after catheteriza-
tion and saline injection. The wall of a flaccid bladder can be
deviated inward by a distended colon, and the acoustic shadow
artifacts generatedby colonic contents often appear like the shad-
ows generatedby calculi." In middle-sizedto large-breeddogs, a
fully distended bladder is also less desirable,but a lower frequency
transducer that has lower resolution will be needed. Also, the
thinner wall is more difficult to visuaiize and measure. Bladder
wall thickness of normal dogs has been shown to vary depending
on the degree of bladder distention.s'zThe wail was reported to be
2.3 mm thick when the bladder was minimaliy distendedand 1.4
mm with moderatedistention (4 ml/kg)."
Bladder sonography can be performed with the dog in either
dorsal or lateral recumbency. Thorough evaluation of the entire
bladder should be done in a transverse plane and also at right
anglesin either a sagittal or a dorsal plane. Accurate assessmentof
bladder wall thickness requires a perpendicular orientation of the
ultrasound beam. Assessment of the cranial wall is challenging
owing to the suboptimal beam alignments3and the adjacent gas-
filled bowel. Side and grating lobe artifactss' generated by the
 The UrinaryBladder 583

Figure 43-2O. Air bubbleartifactscreatedby cystographicprocedures.A,

S mal lai r bubbl esthat causefree l umi nal -type
fi l l i ngdefectsi n the u ri nary
bladder during double-contrastcystography.Bubbles are present in both
ureters.B, "Honeycomb" appearance createdby severaladjacentair bubbles
(arrows).A large air bubble in a mostly fluid{illed bladdermay producea
pseudothickbladderwall. C, Positive-contrast medium and gas may produce
a similar pattem (arrows).The smooth bordersof the pseudothickbladder
wall are produced by the largeair bubbleborderand the actualbladderwall
or outer border of the contrast medium. The region between the arrows
shouldbe recognizedas contrastmedium becauseof its opacitv,
584 A N IMA L S
A B DO M E N- C O MP AN IO N

Figure 43-21, Lateralradiographof a contrastmediumjilled bladderduring intrave-

nous urography.Pseudofillingdelects (arrows)are created by pressureon a partially
di stendedbl adderfrom adj acentabdomi nal
structures.

adjacentcolon can give rise to an erroneousdisplay of echogenic
material in the bladder lumen, and the curved bladder wall can
create additional echoesadjacent to the dorsal bladder wall (Fig.
43-22). Transducer rotation of 90 degrees over such suspicious
areas is often helpful to enable recognition of the proximity of
the colon and determination of the nature of the artifact. Free
intraluminal abnormalities(i.e., calcuii, sediment,and blood clots)
gravitate to the most dependent side of the bladder. In lateral
recumbency,careful examination of the most dependent area of
the bladder is requiredso that small calculi are not missed.Ballotte-
ment is useful for initiating sedimentswirling acrossthe real-time
display.Additional imaging after the animal has been positioned in
the opposite lateral recumbent or standing position allows detec-
tion of gravitation of free intraluminal objects to a dependent
oosition within the bladder.
The normal filled bladder is ovoid in shape,with a slight elonga-
tion caudally at the trigone. The ureters and urethra are not
visualizedunless they become distended with urine. With high-
resolution transducers,the normal bladder wall can be seento be
divided into three distinct layers.The mucosais a thin hyperechoic
surface outlined against the urine, the middle muscle layer is
hypoechoic,and the outer serosallayer is hyperechoic.ttThe cra-
nioventral wall is slightly thinner than other regions. In normal
adult cats,the mean bladder wall thicknessdid not exceed1.7 mm
+ 0.56 mm.s5In normal adult doss with mild bladder distention
(2 mg/kg), the mean wall thicknesswas 1.6 mm, but this thickness
does increasewith body weight.tt Normal urine is anechoic.The
turbulence createdby dischargeof urine through the ureteral open-
ings may generatetransientechojets in the bladder lumen adjacent
to the trigone.56
lntraluminal changes
Urinary calculi, cellular and crystallinedebris, gas,and blood clots
are readily detectedby sonography.Considerationof the gravita-
tional alignment is especiallyhelpful in differentiating calculi and
blood clots that fall downward from gas bubbles that rise upward.
The location of cellularand crystallinedebris and freshhemorrhage
is more variable.Sedimentationtends to occur, and vigorous bal-
lottement will generateswirling echo patternson real-time display.
Calculi. The urine/calculus interface is intensely hyperechoic and
usually appears convex. Multiple calculi often aggregatetogether
and give rise to an irregular,somewhatcontinuous surface,which
makes it difficult for one to distinguish and measure individual
calculi. Distinct acousticshadowswill be observeddeep to calculi
that exceedthe diameter of the sound beam (Fig. 43-23).5?Smaller
calculi may not generatethe characteristic shadows until the beam
focus is optimized at the depth of the calculi. Echogenicity and
acousticshadow generationare independentof chemicalcomposi-
tion, and so radiopaqueand nonradiopaquecalculi can be detected

Figure 43-22. Poorqualty sagittalsonogramof the urinarybladder.Excessivereverberation echoes

{ R)h a vebeen recorded, w hi ch preventseval uati on of the ventralbl adderw al l and natureof the uri ne.
Also , spurl ousechoes{S ) are presenti n the dorsall umen of the bl adderdue to si de (grati ng)l obe
a r tifa ctcreati ngpseudoechogeni c
debri si n the uri ne.The ori gi nand preventi on of these arti fac tshav e
b e e nd iscussedby B arthez.5a
 The UrinarvBladder 585

Figure43-24. Sagittalsonogramof the urinary

bladder
revealsanabnormal
thickening wall(4.5mm)caused
of the cranioventral Theurineis
bv cvstitis.
abnormally
echogenicowingto hematuria.

in the bladder lumen.utA normal sonographicappearanceof the

bladder does not rule out the presenceof mild or acute cystitis or
idiopathic lower urinary tract diseasein cats. Small polypoid muco-
Figure43-23, Sagittal
sonogram of theurinary
bladder
demonstrates
calculi sal massesare also occasionallyobservedwith chronic cystitis. Such
(arrows)
crealing
characteristic
acousticshadows(S), masses are difficult to differentiate from bladder wall neoolasia.
Follow-up sonographic evaluations should be made after treaiment
of the cystitis to re-evaluatesuch masses.Persistenceand especially
by sonography.s6Ballottement usually does not cause calculi to enlargement of irregularly thickened or nodular massesindiiate thb
move, but placing the animal into a standing position clearly allows need for biopsy as neoplasiamay be present. Muscular hypertrophy
detection of relocation of the calculi into the cranioventral aspect secondary to chronic partial lower urinary tract obstruction can
of the bladder. This action helps in differentiating calculi from an also cause bladder wall thickening and may simulate the sono-
adjacent colonic acoustic shadowand dystrophic mineralization in graphic appearance of cystitis. Emphysematous cystitis creates a
the bladder wall. confusing sonographic appearanceas the gas artifacts may obscure
Gas bubbles introduced accidentally by bladder catheterization all bladder anatomy. A radiograph is most diagnostic in these
or cystocentesisappear echogenic and can generateacoustic shad- patients as the gas is more easily recognized within the bladder
ows. Differentiation from calculi is easyas the bubble floats on top lining and wall.
of the urine. Neoplasia. Sonography of transition cell carcinoma of the blad-
Crystalline and cellular sediments generatea variably echogenic der most frequently revealsirregularly shaped,broad-based,hypo-
pattern in more dependent urine. In cats, the crystalline deposits echoic massesprotruding into the bladder lumen.'o Single or multi-
may become thick enough to form a hyperechoic layer confluent ple massesmay be present (Fig. A3-25).The echo pattern can vary
with the bladder wall that creates acoustic shadowing. Vigorous if fibrosis, mineralization, and necrosis have developed. Adiacent
ballottement or placing the animal in a standing position allows
visualization of the characteristic swirling pattern that helps in the
differentiation of thick sediment from calculi.
Blood clots tend to be associatedwith the clinical observation of
severe hematuria. Relative to normal urine, a blood clot appears
commonly as a hyperechoic,nonshadowing, mobile mass.ss'se
Sometimes the clot may be attached to the wall, covering or
adjacent to a traumatic injury or a neoplastic mass. Alternately,
severeacute hemorrhage can filI the bladder and give rise to a lacy
hypoechoic pattern that changeslittle with ballottement or animal
repositioning. A similar appearancecan be observed with severe
proteinuria and fat droplets.60

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
echo texture of the mass. An abrupt transition is observed com-
monly between the neoplastic mass and the adjacent bladder wall.'o
Some highly aggressivecarcinomas and mesenchymal tumors also
tend to spread through the bladder wall. If a small intraluminal
mass occurs, the bladder wall takes on the appearanceof severe
cystitis. Unfortunately, the sonographic appearance of polypoid
cystitis, adherent blood clots, and mural hematomas is similar to
that of bladder neoplasia. The observation of ureter dilation adja-
cent to the bladder wall mass (see Fig. 43-25) and of focal medial
iliac lyrnphadenopathy tends to support the diagnosis of neoplasia.
Cytology or histology or both are necessaryto confirm the presence
of bladder neoplasia.Ultrasound-guided thin-needle aspiration has
been shown to be an accurate technique for obtaining diagnostic
samplesfrom bladder neoplasia.s0
References
1. Fletcher TF: Anatomy of pelvic viscera. Vet Clin North Am 4:471, 1974.
2. International Committee on Veterinary Anatomical Nomenclature: Nomina Ana-
tomica Veterinaria. Vienna, World Association of Veterinary Anatomists, 1973.
3. Evans HE: Miller's Anatomy of the Dog, 3rd ed. Philadelphia, WB Saunders, 1993.
4. Mahaffey MB, Barsanti JA, Barber DL, et al: Pelvic bladders in dogs without
urinary incontinence. ] Am Vet Med Assoc 184:1477, 1984.
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
47:404,1986.
6. Nickel R, Schummer A, Seiferle E, et al: The Viscera of the Domestic Mammals.
Berlin, Paul Parey, 1973.
7. Park RD: Radiology of the urinary bladder and urethra. In O'Brien TR (ed):
Radiographic Diagnosis of Abdominal Disorders in the Dog and Cat. Davis, CA,
Covell Park Veterinary Company, 1981, p 543.
8. White RAS, Herrtage ME; Bladder retroflexion in the dog. J Small Anim Pract
27:735,1986.
9. Adams WM, DiBartola SP: Radiographic and clinical features of pelvic bladder in
the dog. J Am Vet Med Assoc 182:1212,1983.
10. Holt PE: Urinary incontinence in the bitch due to sphincter mechanism incompe-
tence: Surgical treatment. J Small Anim Pract 26:237, 1985.
ll. Patnaik AK, Greene RW: Intravenous leiomyoma of the bladder in a cat. ) Am
Vet Med Assoc 175:381, 1979.
12. Hansen JS: Persistent urachal ligament in the cat. Vet Med Small Anim Clin
67:1090,1972.
13. Root CR, Scott RC: Emphysematous cystitis and other radiographic manifestations
of diabetes mellitus in dogs and cats. J Am Vet Med Assoc 158:72I, 1971.
14. Ellenbogen PH, Talner LB: Uroradiology ofdiabetes mellitus. Urology 81413,1967.
l5. Middleton DJ, Lomas GR: Emphysematous cystitis dueto Clostridium perfringens
in a non-diabetic dog. J Small Anim Pract 20:433,1979.
16. Sherding RG, Chew D): Nondiabetic emphysematous cystitis in two dogs. J Am
Vet Med Assoc 174:1105, 1979.
17. Steyn PF, Lowry J: Positional radiography as an aid to diagnose sandJike uroliths
in the urinary bladder of feline urologic qmdrome cats. Feline Pract 19:21, 199I.
18. Moreau PM, Lees GE, Gross DR: Simultaneous cystometry and uroflowmetry
(micturition study) for evaluation of the caudal part of the urinary tract in dogs:
Studies ofthe technique. Am J Vet Res 44:1769, 1983.
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
dogs: Reference values for healthy animals sedated with rylazine. Am J Vet Res
44:1774, 1983.
20. Moreau PM, Lees GE, Hobson HP: Simultaneous cystometry and uroflowmetry
for evaluation of micturition in two dogs. J Am Vet Med Assoc 183:1083, 1983.
21. Rosin AE, Barsanti JA: Diagnosis of urinary incontinence in dogs: Role of the
urethral pressure profile. J Am Vet Med Assoc 178:814, 1981.
22. Oliver JE Jr, Young WO: Afu cystometry in dogs under rylazine-induced restraint.
Am J Vet Res 34:1433,1973.
23. Mooney IK Jr, Cox EC, Heniman F: Vesical contamination fiom insertions of
everting cot or catheter in inoculated canine urethra. Invest Urol lI:248, 1973.
24. Buchman IW: Kinked catheter: A complication of pneumocystography. I Am Vet
Radiol Soc 8154,1967.
25. FeeneyDA, lohnston GR, Tomlinson MJ, et al: Effects ofsterilized micropulverized
barium sulfate suspension and meglumine iothalamate solution on the genitourinary
tract of healthy male dogs after retrograde urethrocystography. Am J Vet Res 45:730,
1984.
26. Johnston GR, StevensJB, JessenCR, et al: Complications of retrograde contrast
urethrography in dogs and cats. Am J Vet Res 44:1248, 1983.
27. Barsanti JA, Crowell W, Losonsky J, et al: Complications of bladder distention
during retrogradeurethrography.Am I Vet Res42:81d, 1981.
28. Farrow CS: Exercisesin diagnostic radiology. Can Vet I 22:260, 1981.
29. Mahaffey MB, Barber DL, Barsanti JA, et al: Simultaneous double-contrast cystog-
raphy and custometry in dogs. Vet Radiol 25:254, 1984.
30. Ackerman N, Wingfield WE, Corley EA: Fatal air embolism associated with
pneumourethrography and pneumocystography in a dog. J Am Vet Med Assoc
160:1616, 1972.
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.
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.
33. Brodeur AE, Goyer RA, Melick W: A potential hazard of barium cystography.
Radiology85:1080,1965.
34. Mahaffey MB, Barsanti JA, Browell WA, et al: Cystography; Effect oftechnique on
diagnosis of cystitis in dogs. Vet Radiol 30:261, 1989.
35. Johnston GR, Feeney DA: Radiographic Evaluation of the Urinary Tract in Dogs
and Cats: Contemporary Issues in Small Animal Practice. Vol 4: Nephrology and
Urology. New York, Churchill Livingstone, 1986, p 203.
36. Mostofi FK: Potentialities ofbladder epithelium. J Urol 7l:705, 1954.
37. Weichselbaum RC, Feeney DA, JessenCR, et al: In vitro evaluation of contrast
medium concentration and depth effects on the radiographic appearance of specific
canine urolith mineral t1pes. Vet Radiol Ultrasound 39:396,1998.
38. Weichselbaum RC, Feeney DA, JessenCR, et al: Urocystolith detection: Compari-
son of survey contrast radiographic and ultrasonographic techniques in an in vitro
bladder phantom. Vet Radiol Ultrasound 40:386,1999.
39. Stowater JL, Springer AL: Ureterocele in a dog: A case report. vet Med Small
Anim Clin 74:1753, 1979.
40. Scrivani PV Leveille R, Collins RL: The effect of patient positioning on mural
filling defects during double contrast cystography.Vet Radiol Ultrasound 38t355,1997.
41. Archibald J: Urinary system. In Archibald J (ed): Canine Surgery. Santa Barbara,
American Veterinary Publications, 1965.
42. Green RW, Bohning RH Jr: Patent persistent urachus associatedwith urolithiasis
in a cat. J Am Vet Med Assoc 158:489,1971.
43. Osborne CA, Johnston GR, Kruger JM, et al: Etiopathogenesis and biological
behavior of feline vesicourethral diverticula. Vet Clin North Am Small Anim Pract
3:697, 1987.
44. Hansen JS: Patent urachus in a cat. Vet Med Small Anim CIin 67:379, 1972.
45. Osborne CA, Rhoades )D, Hanlon GF: Patent urachus in the dog. Anim Hosp
2:245, 1966.
46. Scherzo CS: Cystic liver and persistent urachus in a cat. ) Am Vet Med Assoc
151:1329, 1967.
47. Park RD; Radiographic contrast studies of the lower urinary tract. Vet Clin North
Am 4:863, 1974.
48. Osuna Dl, Stone EA, MetcalfMR: A urethrorectal fistula with concurrent urolithi-
asis in a dog. ) Am Anim Hosp Assoc 25:35,1989.
49. Biller D, Kantrowitz B, Partinton R, Miyabayshi T: Diagnostic ultrasound of the
urinary bladder. J Am Anim Hosp Assoc 26:397, 1990.
50. L6vell6 R, Biller D, Partington B, Miyabayashi T: Sonographic investigation of
transitional carcinoma of the urinary bladder in small animals. Vet Radiol 33:103,
1992.
51. Berry CR: Differentiating cystic calculi from colon: Vet Radiol 33:282,1992.
52. GeisseAL, Lowry JE, SchaefferDJ, Smith CW: Sonographic evaluation of urinary
bladder wall thickness in normal dogs. Vet Radiol Ultrasound 38:132,1997.
53. Douglas JP, Kremkan FW: Ultrasound corner: The urinary bladder wall hlpo
echoic pseudolesion. Vet Radiol Ultrasound 34:45, 1993.
54. Barthez PY, L6vell6 R, Scrivani PV: Side lobes and grating lobes artifacts in
ultrasound imaging. Vet Radiol Ultrasound 38:387, 1997.
55. Finn-Bodner ST, et al: Sonographic architecture and morphometric evaluation of
the nornal feline urinary bladder wall. In Proceedings of the Annual Meeting of the
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?

2. With good serosal detail noted within the abdomen, what

conditions may causethe bladder not to be visualizedradiographi-
cally?

3. On a lateral survey abdominal radiograph, you obserue a l-

cm, round, lucent area with well-defined margins in the center of
the urinary bladder. What is producing this?

4. A dog is presented to you after it has been hit by a car. On a

Iateral abdominal radiograph, the serosal detail is poor and you
cannot distinctly see the urinary bladder. You suspect a ruptured
urinary bladder. Which contrast examination would be most infor-
mative?

5. Why is moderate bladder distention recommended for doubie-

contrast cystography?

6. What are the three tlpes of artifacts that may be created by

gas bubbles within the bladder? Figure 43-27
 CHA P T E R
44
The Urethra
. Robert D. Pechman,Jr.
I Anatomy
The urethra is a sphincter and a conduit for urine from the
bladder.' In females,the urethra is shorter and wider than in males;
it terminates at the external urethral orifice on the ventral floor of
the v-agina. An external urethral sphincter is present in female
oogs.'
In males, the urethra is long and thin and may be subdivided
into three parts (Fig. 44-1). The prostatic urethra extendsfrom the
bladder to the caudal border of the prostate gland. The membra-
nous urethra extends from the caudal margin of the prostate gland
to the urethral bulb of the penis in dogs and to the bulbourethral
glands in cats. In both species,the distal extent of the membranous
urethra is approximately at the caudal margin of the ischium. The
penile urethra extends from the caudal edge of the pelvis to the tip
of the penis. The penile urethra is considerably smaller than the
membranous urethra in cats; in dogs, it is partially surrounded
dorsallyby the os penis.r''
I Survey radiography
, .4
Radiographic evaluation of the urethra is performed most often in
male dogs.' Radiographic examination of the urethra in male cats
may be of value in patients with feline urologic syndrome with or
without urethral obstruction.3 Radiographic examination of the
urethra is not often performed in female dogs or cats.
Survey radiographs of the urethra are rarely helpful, but they
should be carefully examined for signs of urethral disease.Radio-
paque urethral calculi may be seen on survey radiographs. Abnor-
mal cranial displacementof the urinary bladder may occur second-
ary to urethral rupture. Pelvic fractures, particularly in male dogs,
may result in urethral injury. Contrast urethrography is indicated
in all instancesof susoectedurethral disease.3'a
584
I Gontrast urethrography
Water-soluble organic iodide contrast media should be used. Oil-
basedcontrast media, barium suspensions,and air should not be
used because of the risk of urethrocavernous reflux and contrast
medium embolization.l' H Positive-contrast medium should be
diluted with sterile saline or sterile water to approximately I5o/oof
the original concentration.r, a
A balloon-tipped catheter should be used.' The catheter is in-
serted into the urethra and the balloon inflated to prevent reflux
of contrast medium. A 10- to 15-mL volume of contrast medium
is usually used in dogs; 5 to 10 mL is adequatein cats.Radiographic
exposuresshould be made during injection of the last 2 or 3 mL
of contrast medium. A lateral view is usually adequatefor diagnosis
of urethral disease,but right and left ventrodorsal oblique projec-
tions are sometimes helpful. Ventrodorsal views are not usually of
value. In the lateral view, it is important to position the patient
with the pelvic limbs pulled cranially to avoid superimposition of
the femurs over the urethra.r,aDistention of the urethra, particu-
larly the prostatic urethra, and overall quality of the contrast
urethrogram may be improved if the urinary bladder is fully dis-
tended with urine, contrast medium, or sterile saline during ur-
ethrography.sRetrogradepositive-contrast urethrography should be
performed with care because complications can result.t, 8 Fortu-
nateiy, most of these potential complications are transient and
reversible.
Urethrography can be more difficult in females. As in males, a
balloon-tipped catheter must be inserted into the urethra, the
balloon inflated, and positive-contrastmedium injected.An expo-
sure is made during the injection. The normal urethral mucosal
surface is smooth and mav be characterizedbv severallinear folds
(Fig. 44-2).a Vaginourethrography is u ,".ond, and slightly easier,
method of evaluating the urethra in females. A large balloon-
Figure tI4-7. Normal positive-contrast retrogradeurethrogramin a
dog. A balloontippedcatheteris presentwithin the penileurethra.The
urethrais dividedinto three segmentstA, The prostaticurethra;B, The
membranous and C The peni l eurethra.
urethra; The urethralmuc os ai s
smooth,andthereare no fi l l i ngdefectsi n the contrastmedi umc ol umn.
 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

Figure 4tF3. Transabdominal ultrasoundimageof the same female dog

as that in Ftgure44-28. A moderatelyechogenictissue mass /anowsl has
thi ckenedthe urethralw al l and extendsi nto the urethrall umen near the
bladder neck. Diagnosis:transitionalcell carcinoma.(Courtesyof David
Biller,DVM, KansasState Universitv.)

I
I
Ii
,it

Figure 444. Positive-contrast retrogradeurethrogramIn a

male d o g w i t h a s o l i t ar yu r e th r a ca l lcu lu s.ln su r ve yr a d io -
grap h sa, m i n e r a l - o p a city s s se e nn e a rth e p r o xim a l
ca lcu lu wa
os penis.With urethrography, the calculusappearsas a radio-
luc e n ti n t r a l u m i n af ill l i n gd e fe ct in th e co n tr a stm e d iu mco l-
umn (arrow).The margins of the calculusare smooth and
s har o l vd e f i n e dT. h e r e ma in d eor f th e u r e th r ais n o r m a l.

Figurc 4/r-5. Positive-contrastretrogradeurethrogramin a

male dog with fractures of the pelvis and femur. There is
extravasationof contrast medium into the oerinealand pelvic
soft tissues.Completetransectionof the membranousurethra
was found at surgery.
 The Urethra 591

Figurc 4/t-6. Positive-contrast urethrogramin a male dog.

There is extravasationof contrast medium through a urethral
l a c e r a t i o ni n t o t h e ca ve r n o u stissu e so f th e p e ns. T h e r e is
o p a c i f i c a t i oonf t h e d o r save
l ino f th e p e n isb y co n tr a stm e d jum
(arrows).The patientwas examinedbecauseof stranguria.A
fracture of the os penis at the site of the urethrallaJeration
*,i
w a s a p p a r e n itn s u r v e yr a d io g r a p h s.
No te d r a in a q eo f co n tr asr ,llil.'
:rrrliilrr,
m e d i u mi n t o r h e c a Ld ave l n aca va . .r,,,lt:,,

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.

congenitalor acquired.r 9. Wingfield WE: Lower urinary tract injuries associated

with pelvic trauma. Canine
Prcct 1i25, 1974.

References 10. Kleine LJ, Thornton GW: Radiographicdiagnosis

of urinary tract trauma. J Am
Ani m H os p As s ocZ :318,1971.
RD: Radiology of the urinary bladder and urethra. ln O,Brien TR (ecl): RD: Urinary trauma in dogs and cats:A review.j Am Anim
_l..Park 11.^f":!.- Hosp Assoc
Radiographic Diagnosis of Abdominal Disorders in the Dog and Cat. philadelphia, 18:33,1982.
WB Saunders, 1978, p 605.
l2' Hanson JA, Tidwell AS; urtrasonograprric
appearanceof urethral transitional cell
2. Osborne CA, Low DG, Finco DR: Canine and Feline Urology. philadelphia, carcrnomain ten dogs. Vet Radiol Ultrasound Zl:q,
WB l.gg1.
Saunders, 1972, p 7.
1,3.Osborne-CA, Engen MH, yano BL, et al:
Congenital urethrorectalfistula in two
GR, FeeneyDA, Osborne CA; Urethrography and cystography jn cats: I. qog( . , Ar n Ver M ed As s oc166:999,
*3..Johnston 1975.
normal radiographic anatomy, and artifa-cts.iomp Contin Educ pract Vet
Tfl-"igl::,
4:823, 1982.
K Ouestions
4.,Ticer JW Spencer CP, Ackerman N; positive contrast retrograde urethrography:
A
useful procedure for evaluating urethral disorders in the dog. i.t nudiol Zt:1,
iSgO.
l. Tiue or False.The male urethra is subdividedinto three parts:
the
5. Johnston GR, JessenCR, Osborne CA: Effects of bladder distentlon
on canine and
Prostatic urethra, the membranous urethra, and the penile urethra.
feline retrograde urethrography. Vet Radiol 24:2j1, t983.
2. True or False.Contrast urethrographyshould be performed
6. Ackerman N, Wingfield WE, Corley EA; Fatal air embolism associated on
with all patients with urethral disease.
p ne u mo u re th ro g ra p h y and pneumocystogr aphy in a dog. Ani
J Vet M ed As s oc
160:1616, 1972.
3..What.abn-ormalradiographicfindingsarepresentin this lateral
7. Johnston GR, StevensJB, lessen CR, et al: Complications of retrograde radrographot the caudalabdomenand perinealregion
contrast of a male
urethrographyin dogs and cats.Am J Vet Res44:1248,1983.
dog (Fig. 4a-l?

,,
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
A. Room air.
B. 30o/obarium suspenslon.
C. Oil-basedcontrast medium.
D. Water-solubleorganic iodide contrast medium.
E. Carbon dioxide.
5. Tlue or False. Urethral distention and overall quality of a
urethrogram are improved if the bladder is ful1y distended when
the examination is performed.
6. True or False. Vaginourethrography is an old and outdated
technique for evaluatingthe urethra in female dogs and does not
differentiate the normal mucosal surface from the abnormal.
7. True or False.Intraluminal filling defectsin a positive-contrast
CHA P T E R
45
The Prostate Gland
r Jimmy C. Lattimer
I Normal anatomy
The normal prostateis recognizableby its shapeand opacity and
by the relationship of the gland to the organs around it. If the
shape or position of the gland is altered, the gland may not be
recognizableother than as a nondescriptopacity betweenthe blad-
der, rectum, and pelvis.'Becausethe prostate is usually in direct
contact with the rectum, the dorsal border is often difficult to see,
especiallyif the rectum contains feces.A full rectum may also
completelyobscurethe prostateon the ventrodorsalview. Visual-
ization of the prostateis dependenton the presenceof surrounding
fat; it may not be seen in very thin animals or in animals with
fluid in the area of the neck of the bladder.In instancesin which
a male dog has been castratedor was given estrogen,the prostate
may be so small tl.ratit is not visible radiographically.
I Diseases of the prostate
Intrinsic diseaseof the prostateusually resultsin prostatic enlarge-
ment. Enlargementmay also occur in responseto extraprostatic
diseases such as an androgen-producingtesticulartumor and orchi-
tis.2Becauseof the closefunctional associationof the prostateand
testes,any animal with prostatic diseaseshould also be examined
(preferablyultrasonographically)for testiculardisease.
The most common prostatic abnormality is benign prostatic
hypertrophy, in which the prostate enlargesowing to increased
volume in the intercellular and ductal spacesrather than to in-
creasedintracellularvolume or cell numbers.Thus, oncethe disease
reachesa certain point, the development of dilated cystic spaces
and ducts is inevitable. Solid and cystic hypertrophy are therefore
different stages of the same disease, with the latter being the
advancedform.'' 3 The size of the cystic spacesvaries from micro-
scopicto large;thesespacesmay become so large that they distort
the shape of the entire gland. A cystic prostate may have cysts of
many different sizes.
Another common cause of prostatic enlargementis prostatitis,
which is usually bacterial.' The infection may arise within the
prostate or it may extend from other sources,such as the bladder
urethrogram can be caused by air bubbles, calculi, and prostatic
hyperplasia.
8. List three possible causes of intramural fiiling defects in a
positive-contrasturethrogram.
9. True or False. Diagnostic information available from contrast
urethrography and from urethral ultrasonography is the same for
both examinations, so utilization of both imaging techniques in
the samepatient is contraindicated.
10. True or False.Extravasationof contrast medium in a positive-
contrast urethrogram indicatesdisruption of the integrity of the
urethra.
Answers begin on page 727.
or testicles.s Becausemany antibiotics do not readily penetratethe
prostate,the gland may also be a reservoir for reinfection or for
primary extensionto other organs.6'?The degreeof inflammation
is dependenton the type of organismpresentand the condition of
the prostatebefore infection. A normal prostateis more resistant
to infection than is a hypertrophied gland with many secretion-
fi1led cystic spaces.The inflammation may vary in severity from a
mild transient Drocessthat causesminimal or no clinical disease
to a fulminating hemorrhagic processthat rapidly destroys the
entire gland.8 The latter may result in rupture of the capsule
with extension of infection to the peritoneal cavity, resulting in
peritonitis.T
Chronic, recurrent prostatitis may result in a scarred,fibrotic
prostate that is smaller than normal. Chronic scarring may result
in stricture of the urethra.' A prostate such as this may not be
recognizedradiographicallyunlessa urethrogram is performed.
Prostaticabscesses may form as a result of prostatitisor primary
cystic disease.As with cyst formation, abscesses may be small or
large. Large abscesses distort the shape of the gland and may
eventually rupture, causing peritonitis. As has been previously
stated, cysts form in advancedbenign hypertrophy and are usually
contained within the gland. Occasionally,cysts become so large
that the shape of the gland is distorted, and the predominant
opacity seenon the radiograph is due to the large cyst. Such large
cysts are also referred to as paraprostatic cystsbecausethey are no
longer confined within the gland. These cysts are usually sterile but
may become infected and abscessed.to
Occasionally,cysts result from neoplasia.rrFormation of func-
tional neoplastic secretory cells without an accompanying ductal
system results in a cystic structure lined with neoplastic epithelium.
Osteocollagenousretention cysts are rare and of unknown origin,
but they do not appear to be the direct result of cystic hlpertro-
phy." A rare form of cyst, which is truly paraprostatic, is cystic
enlargementof the wolffian ducts, called uterus masculinus.)3 En-
largement of the wolffian ducts results in a bilateral tubular mass
that resemblesuterine enlargement. The prostate itself may or may
not be enlarged and is usually not distinguishableas a separate
opacity.'

Prostaticadenocarcinomais relativelyuncommon.'','s When it
occurs, this tumor is often advancedat presentation, with metasta-
sis to regional lymph nodes, the pelvis, and distant sites such as
the liver and lungs.l618In some dogs, the prostate is massively
enlarged by the tumor, and in others the degree of enlargement is
minimal. Small in situ prostatic carcinomasare unusual,but they
do occur; they are usuallydiscoveredas a result of metastasisrather
than as local effects. Prostatic neoplasms are often secondariiy
infected or necrotic, and affected dogs may therefore have clinical
signs of prostatitis.Thesepatients are difficult to diagnose,unless
signsof metastasisare present,becauseof the tendencyof prostati-
tis to overshadowneoplasia.le 21
Clinical signs
The clinical signs of prostatediseaseare usually referableto either
urinary or rectal problems. Stranguria, hematuria, and pyuria are
commonly seen.5'8' ro'13Complete urethral obstruction is unus-
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
dyschezia,with small or ribbon-like stools.s'" As the enlarging
prostate displacesthe colon dorsally,it compressesit againstthe
sacrum and pelvis, resulting in a decreasein stool diameter (Fig.
45-1). Extreme straining to defecatemay result in small amounts
of fresh blood in the stool. Severe rectal compression by the
prostatemay causeclinical and radiographicsigns of constipation
or obstipation. The problem is then critical and immediate, and
definitive treatment must be instituted. Another lesscommon but
important complaint is a pelvic limb gait abnormality.The animal
may refuse to climb stairs and jump. Owners often believe the
animal has developeddegenerativejoint diseasein the hips. Such
animalsmay havesevere,activesepticprostatitis.s'8 The pain caused
by the prostatic infection is markedly exacerbated by walking,
climbing, and jumping. Both pelvic limbs are usually affected
uniformly becausethe pain is central. These animals are also
usually sensitiveto palpation of the caudal abdomen. There may
also be some erythema of the skin due to inflammation in this
area. Gait abnormalitiesare seen rarely in uncomplicatedbenign
prostatic hypertrophy.
Radiographic changes
Although ultrasonographyhas enhancedvisualizationof the pros-
tatic parenchyma,retrograde urethrography is still an important
and useful imaging procedurethat should be performed in patients
with suspected prostaticdisease.
Becauseof the intimate relationship between the prostate and
the urinary bladder,prostatomegalydisplacesthe bladder cranially
(Fig. 5-2). If prostatomegalyis uniform, bladder displacementis
cranial along the floor of the abdomen.If prostatomegalyis eccen-
Figure 45-1, Prostaticenlargement.fhe white arrowheads
l a r g ino f th e p r o sta tewh
i n d i c a t et h e c r a n i am , ich is d isp laci ng
t h e b l a d d e rc r a na lly.No ticeth e d istn ct fa t o p a q u etr ia n g ul ar-
s h a p e dr e g i o nb e t w e e nth e ve n tr aca i u d am l a r g ino f th e b a dder
and the cranialventra margin of the prostate (blackarrows).
T h e e n l a r g e dp r o sta teis d isp a cin gth e ca u d a lco lo n d o r sal l y
and indentingtt (blackarrowheads).
,r,igF
The ProstateGland 593
tric, as often occurs with cysts and abscesses,the direction of
bladder displacement may be different. Dorsal prostatomegalyby a
cyst or abscessmay extend dorsal to the bladder, compressing it
against the floor of the abdomen (see Fig. 45-2). Alternatively,
with ventral prostatomegaly, the bladder may be elevated (Fig.
45-3). A large prostatic cyst or abscessmay extend ventral to the
bladder,also resulting in craniodorsaldisplacementof the bladder.
This latter appearanceof elevationof the bladder may also be seen
with severebenign prostatic hypertrophy (seeFig. 45-3).
The other major radiographic sign of prostatomegalyis dorsal
displacementof the colon (see Figs. 45-1 and 45-2). The colon
normally lies in contact with the dorsal or dorsolateralsurfaceof
the bladder. As prostatomegalydisplacesthe colon dorsally, contact
with the bladder is lost. Radiographicaliy,rhere is separationof the
ventral border of the colon and the dorsal border of the bladder.
In a male dog, such a finding is virtually confirmatory of prostato-
megaly.5
Prostaticenlargementmay causenarrowing of the colon lumen.
Radiographically,this compressionmay be visible, or the colon
may simply become confluent with the prostatemassat the pelvic
inlet (Fig. 45-4). The latter appearancedoes not usually occur
unless the prostate is very enlarged.The colon is often displaced
laterallywithin the pelvic canal by a prostatic mass.
The urethra, although not really displacedrelative to the pros-
tate, may be elevatedfrom the pelvic floor or displaced laterally by
an enlargedprostate.Urethral displacementis most often seenwith
asymmetrical prostatic disease,such as tumor and abscess.The
urethra is also often elongatedby its passagethrough an enlarged
prostate. The position of the urethra is impossible to ascertain
unlesscontrast medium is used to outline it (seeFig.45-2).
A tremendously enlarged prostate displacesother abdominal
organs cranially.Huge prostatic lesions usually lie on the floor of
the abdomen, so there is some dorsal displacementof the remain-
der of the abdominal contents. Prostatii and paraprostaticcysts
may become so large that they reach almost to the costal arch.rl
With massesof this magnitude, organ displacementis so severe
that the actual source of the mass may be difficult to determine
without the use of specialradiographicproceduresor sonography.
All common prostate diseasescauseenlargement.As is the in-
stance with most organs, the enlargement may be symmetrical
(diffusein origin), asymmetrical(focal in origin), or a combination
of the two. Hypertrophy and prostatitisare examplesof symmetri-
cal enlargement,whereasneoplasiaand cystsare examplesof asym-
metrical enlargement.Large prostatic and paraprostaticcysts and
abscesses are generallycombination lesionsthat involve the entire
prostate, but a single lobe predominates as the source of the
radiographic lesion.8Becauseit is difficult to preciselydefine the
shape of the normal prostate, it may be difficult to determine
l,,,.rrrl!'l,r,,,lr'
,ttuti,t,,,,
trii€uu'itlirrl
...j.:):..:::l:,:)..
 594 A N IMA L S
A B DO M E N-C OMP AN IO N

Figure 45-2. A very large,dorsallylocatedparaprostatic cyst

(C ) that i s di spl aci ng
the bl adder(B ) crani al l yand v entral l yand
the prostate(P) ventrally.Noticethat much of the cyst is within
the pel vi ccanaland di spl aci ngthe rectum dors al l yThi . s is a
markedl vasvmmetri cl esl on.

Figure 45-3. l\,4arked prostaticenlargementwith dorsalele-

v at io no f t h e n e c ko f t h e bla d d e {r N) .In e xtr e m ein sta n ce s, th e
prostatemay lift the bladdercompletelyaway from the floor of
t he a b d o m i n aw l a l l , N o t e th e r e flu xo f co n tr a stm e d iu m in to
the prostateand the way the enlargedprostateencompasses
t he n e c ko f t h e b l a d d e rA. ca th e te rin th e u r e th r aca n b e visu a l-
iz ed.

Figurc 454, Survey radiographof an extremely enlarged

prostate.fhe black arrowheadsindicatethe ventraland dorsal
margins of the prostate.fhe white arrowheadsindicatethe
ventralmarginof a second lobularmass form of the prostate.
The urinarybladderis at the extreme left of the figure superim-
posed on the ai r-fi l l ed
bow el l oops.S ubseque nts tudi esi ndi -
cated that there were multiplecysts arisingfrom the prostate.
lt is very easy to confusethe second cyst (white arrowheads)
with the urinarvbladder.

whether the enlarged prostate is symmetrical or asymmetrical when
enlargement is mild. If the enlarged prostate is relatively symmetri-
cal in its relationship to the bladder, the enlargement is probably
symmetrical; if not, the enlargement is asymmetrical (Fig. 45-5;
see also Fig. a5-2).
Prostatic size that exceeds90% of the distance from the pubis to
the sacral promontory is suggestiveof a mass lesion (cyst, abscess,
or neoplasm).23 The actual degreeof prostatic enlargementvaries
tremendously, however. For instance, prostatic size may vary from
slight enlargement to 10 times normal size for benign prostatic
hlpertrophy, and the prostate may actually decrease in size in
chronic prostatitis. If prostatic cysts or abscessesare present, the
prostate shadow may be as great as 20 or more times normal size,
or the degree of enlargement may be minimal. Acute prostatitis
and neoplasia do not usually cause huge enlargement, as is seen
with hypertrophy and cyst formation. Some small in situ prostatic
tumors are not recognizeduntil the animal is examined for another
problem, such as cough and lamenesscausedby metastasis,or they
may be discoveredas an incidental finding at postmortem.
It is important where possible to evaluate the margination of
the prostate. The presenceof adequate amounts of abdominal fat
is essentialto enable visualization of the prostatic margin, In the
presence of emaciation, normally thin animals (such as sight-
hounds), pelvic trauma, or abdominal effusion, the prostatic mar-
gin and even the entire prostate itself may be indistinctly seen. If
the prostate has a smooth margin that is easily seen, the disease
involving the gland is likely to be benign or is slowly progressing
(see Fig. 45-l), such as benign hypertrophy and low-grade or
chronic prostatitis. A rough or indistinct margin in the presenceof
adequate abdominal fat is more likely to be due to an acute or
aggressiveprocess,such as neoplasiaor prostatitis (Fig. 45-6).':0'
24'2s \!hen the margin is indistinct or is not discernible, the
impression is that of alocalized peritonitis in the caudal abdomen.
Except for prostatic rupture with hemorrhage, this assessmentis
probably accurate. There is usually some secondary inflammation
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
poorly marginated, although this occurrence is the exception rather
than the rule. Occasionally,a cyst or abscessmay form in the pelvic
canal; such lesions may not be readily visible on survey radiographs
nor produce the usual displacement of the bladder.26These lesions
do, however, produce marked displacement and compression of
Figure 45-5. Asymmetricenlargementof the prostate.fhe whtte
arrowheadsindicatethe dorsaland ventralmarginsof the prostate,
and the asterlskindicatesthe point at which the bladderneck enters
the prostate.The enlargementof the prostateis predominantlyven-
tr a la n d i s d i s p l a c i nth
th e b l a d d e d
Be ca u seit is n o t d istended,
g e u r e th r ad o r sa lly.
r o e s n o t lie o n th e flo o ro f th e a b d o m e n .
The ProstateGland 595
the rectum and are therefore recognized as an intrapelvic mass.
The lack of regional peritonitis associatedwith the large abscess
may be due in part to the thickness of the capsule and to the low
virulence of the organism. It is seldom possibleto distinguish a cyst
from an abscesson the basis of radiographic examination alone.
Any change in the opacity of the prostate from its normal
soft-tissue opacity indicates severe or chronic disease.Areas of
calcification within the gland are a sign either of long-standing
prostatitis or of neoplasia(Eig. 45-7).13,2r,23 Most prostatecalcifi-
cation is a result of neoplasia. Therefore, calcification should be
considered a serious finding that warrants biopsy.,a
The presence of gas within the prostate is also an important
sign. Becausethe prostate does not normally communicate with
any air-containing organ, there is no reason for it to contain gas.
Such a finding is considered evidence of a gas-forming bacterial
cystitis unless the gas opacity can be attributed to an overlying gas-
filled bowel loop. Coliform or clostridial prostatitis results in severe
hemorrhagic necrosisofthe gland, potentially causing a generalized
peritonitis. Becauseof the rapidly fatal course of these infections,
identification of non-iatrogenic gas within the prostate should be
viewed as an unfavorable prognostic sign. Even if the animal
survives,severepermanent scarring ofthe prostate is likely. Sterility
and urinary retention or incontinence may become long-term se-
quelae to such scarring.
The prostate may contain air becauseof reflux from the bladder
during a negative- or double-contrast cystogram (Fig. a5-8). A
small amount of reflux into prostatic ducts is a normal but not
consistent occurrence. Simple filling of the ducts with air does not
necessarilyindicate prostatic disease.Filling ofair in pockets within
the prostate is abnormal, however, and is most often associated
with cyst formation secondary to benign hypertrophy.
Palisade-type periosteal proliferation is sometimes seen on the
ventral aspect of the caudal lumbar vertebrae and pelvis. Such
proliferation is suggestive of regional metastasis from prostatic
neoPlasia.20-23'27'28
I Special radiographic
I procedures for evaluating
I the prostate
The only special radiographic technique that has been found to be
uniformly useful in evaluation of the prostate is the positive-
.:'"', l$]l
.:. . ..ll$:ii
... l:i6llj
Cg]::];:-.
Se]nt:,
:a:l
,{@:l
ffi
5 96 AN IM AL S
A B DO M E N -C O MP AN IO N

Figure 45-6. Prostaticneoplasia.lt is impossibleto separate

the bl addershadowfrom that of the prostateon thi s radi ograph.
The irregulargrowth of the prostatic mass has obliteratedthe
normalmargi nof the bl adderand i nvadedthe fat aroundthe nec k
of the bl adder.

Figure 45-7- Calcification in the prostate.This irregularcalcr-

ficationwithin the prostate (white arrowheadslcould be mis-
takenfor periostealreactionon the pubis.However,the calcifi-
c at i o n i n d i c a t e db y t h e a r r o ws h a s a wisp y m a r g in a n d is
c en t e r e dt o o f a r d o r s a llywith in th e p e lvicca n a lto b e a r isin g
f ro m t h e p e l v i s .S u c h a Je sio nis su g g e stiveo f n e o p la siab u t
c ou l da l s or e s ut r r o ' n or o sL a titis.
 The ProstateGland 597

Figure 45-8. Cavitationof the prostate.During a double-contrast cysto-

gram an air-filledcavity was noted within the prostate/A/. This cavity was
irregularand thick walled.A urethrogram(B)clearlyindicatesthe communica-
tion of the cavitywith the urethra.

Figure 45-9. Fillingof the prostaticducts with contrast medium.

Th e r ea r e n o c a v i t i e sfille db y th is co n tr a stm e d iu m .T h is is a normal
f i n d i n go n u r e t h r o g r a p h y.
598 A N IMA L S
A B DO M E N -C O N /IPA N ION

contrast retrograde urethrogram. This procedure allows evaluation

of the urethra itself and the position of the urethra in relation to
suspectedprostatic disease.Asymmetrical positioning of the ure-
thra indicates that the enlargementis either extrinsic to the prostate
or is occurring asymmetrically within the prostate (see Fig. 45-2)'
the latter being more common.23Invasion or stricture of the ure-
thra in association with a prostatic mass is a poor prognostic
finding not only becauseof the danger that a urinary obstruction
might occur but also becauseit is a sign that aggressivediseaseis
present.23Evidenceof either prostatic asymmetrical enlargement or
urethral abnormalities is a positive indication for prostatic biopsy.
A secondary benefit of the urethrogram is that it identifies the
true location of the urinary bladder. In some instances,abdominal
masses,such as omental tumor and enlarged retained testicle, lie
just cranial to the bladder. This positioning closely mimics the
appearanceof an enlarged prostate that is displacing the bladder
cranially. Such tumors obviously present different clinical and diag-
nostic problems and should be treated accordingly.
Positive identification of the bladder and its position relative to
the prostate also has definite benefits when the diseaseprocessdoes
involve the prostate. It is not always obvious from survey radio-
graphs or palpation what is prostate and what is bladder (see Fig.
45-4). This identification is necessary if a blind percutaneous
aspirate or biopsy of the mass is to be attempted rather than a
biopsy via laparotomy or with ultrasonographic guidance' When
the oositions of the bladder and urethra are identified with a
uretlirogram, the chances of injury to the urinary tract during
biopsy procedures are lessened.
Urethrography is easily performed in the male dog, and there
are several methods that may be used (see Chapter 44).zs'zoUt-
ethrography provides only indirect evidence of prostatic disease.If Figurc 45-1O. The smallfillingdefect\blackarrowheads are at ventral
the urethra is deviated around a large mass or does not pass aspectof fillingdefect)in the dorsalwallof the prostatic
urethrais a normal
directly through the center of the prostate, the diseasewithin the structure,
thecolliculus
seminalis. lt should
notbemistaken fora lesion caused
bv Drostaticor urethral
disease.
prostate is asymmetrical, such as a cyst. If the urethra passes
directly through the middle of an enlarged prostate, the disease
processis more likely to be diffuse throughout the gland, such as
hypertrophy or prostatitis. tional cell carcinoma.These small lesionsmay not be detectedon
Direct signs of urethral diseaseof prostatic origin are urethral a cystogram because they are obscured by the internal urethral
stricture, ulceration of the mucosa, and filling defects within the sphincter, which is actually encircled by the prostate.2T
urethra. Ulceration or stricture of the prostatic urethra should be
regarded as highly suggestiveof neoplasia of the prostate.6''?3
Extravasation of contrast medium into the prostate should not I Sonography for evaluating
be interpreted as abnormal as long as only the prostatic ducts fill
with contrast medium (Fig. a5-9). This appearanceis often seen
I the prostate
in animals with a normal prostate.3' Only if definite pooling of Over the last 10 years, there has been tremendous growth in the
contrast medium within the prostate is seen should extravasation use of diagnostic ultrasonography for the diagnosis of prostatic
be considered abnormal. Large, irregularly shaped cavities with disease.Ultrasonography is easy,safe,and inexpensiveto perform.
rough walls that communicate with the urethra or cavitary smooth- The ultrasonographic examination can often be performed in less
walled lesions containing intraluminal massesare often associated time than a contrast examination, but the major advantage of
with neoplasia;biopsy is indicatedin thesecases(seeFig. 45-8).'5 ']6 ultrasonography is its ability to image the actual structure of the
Conversely, if extravasation does not occur, the prostate is not tissues within the prostate. This is very important for delineating
necessarily normal or solid. Many times, large cavitary lesions, the differences between mass lesions such as cysts and tumors.
such as cysts and abscesses,attain their size becausethey do not Thus ultrasonography has nearly supplanted urethrography for the
communicate with the urethra.l'' t3'" If these cavities do fill with diagnosis of prostatic diseasein practices in which it is available.
contrast medium, they are usually ovoid, with smooth walls. The sonographic examination of the prostate should include the
The normal prostatic urethra as seen on the urethrogram has a bladder and testicles. These associatedstructures may be second-
smooth mucosal border. The urethra is usually slightly greater in arily affected in prostatic disease,or they may actually be the site
diameter near the center of the prostate and tapers slightly at the of the primary disorder while the prostate is the secondary site of
cranial and caudal borders. The degree of the central dilatation is involvement. The ultrasonic examination of the orostate should be
somewhat dependent on the size of the prostate, the diseasepres- performed from the prepubic position. The mijority of prostate
ent, the degree of bladder distention, and the amount of pressure glands can be effectively and compietely examined using this ap-
applied during injection.3'A small filling defect in the dorsal wall of proach. Very small normal glands such as those seen in neutered
the urethra near the center of the prostate representsthe colliculus dogs may occasionallynot be seen,but pathologic glands are rarely
seminalisand is a normal finding (Fig. a5-10). In some dogs,there not seen cranial to the pubis. The examination should consist of
may also be a normal groove in the colliculus. images of the prostate in both the transverse and parasagittal
The point at which the prostatic urethra joins the trigone of the planes. The prostate is found caudal to the bladder and usually is
bladder should be carefully evaluated. It is possible to detect small most easily imaged from the right side of the os penis when the
filling defects of mucosal ulcers that may be early lesions of transi- dog is on his back. In some dogs,it is necessaryto anglethe probe

Figure 45-11- This moderatelyenlargedprostateis difficultto
imagesonographically becauseof its intrapelvlclocation.The cranral
third of the prostate is seen between the bladder (blackarrow_
heads)andthe pubicbrim shadow (whitearrowheadsl.lf the proper
pro b ei s a v a i l a b i et h, i s p r o sta teco u ldb e im a g e dm o r e co m p lei el y
usi n ga t r a n s r e c t aalp pr o a ch .
caudally to see the caudal pole of the prostate where it lies just
dorsal to the pubic brim (Fig. 45-11). Mensuration of the prosiate
and lesions within the prostate is easily performed with thi use of
ultrasonography and has been found to be accurate,33
The normal prostate is uniformly echogenicwith an echogenicity
. of
that is very similar to that of the surrounding fat. The urithra is
usually seen as a small echolucencyin the center of the eland with
a very narrow band of slightly hyperechoic tissue adjicent to it
(Fig. 45-12). Although the position of the urethra can usually be
ascertained, involvement of the urethra by a diseaseprocess can
Figure 45-12, Transverse sonographicimageof normalprostate.The organ
marginsare distinct,and the echogenicityis very close io that of the iur_
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
(whitearrowheadsl.Mild artifactualstreakingof the prostateis present.
The ProstateGland 5gg
b. inferred sonographically and must be confirmed by ur_
:-l-tl
ernrography.
Benign pro^statichypertrophy usually presents a sonographic
appearance of a uniformly enlarged gland that is mildly"hyper_
echoic (bright) and has a_smootli maigin. The dorsal portion
the gland
Tay q. enlarged to a greater iegree than the ventral, or
yt..,::rr1, but the changesare symmetrical from right to left (Fig.
45-lJ)..lhrs symmetry may be lost as the hypertrophy
increasJs
rn severlty ancl enters the cystic stageof the disorder. As cysts
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
catclhcatton aloneshould not be made.
Malignant neoplasia of the prostate in the dog is usually ad_
vanced at the time of presentition. These are hlghly aggressive
clrseaseprocessesthat destroy the architecture oflhe gl-"-rrd,.._
600 AN IM AL S
A B DO M E N-C O MP AN IO N

Figwe 45-13. Benign prostatichypertrophy.The prostate is still

symmetricas seen in this transversesectionbut is increasedin echo-
geni ci tyas comparedw i th the surroundi ng fat. The ma rgi nsare not
qui teas di sti nctas normal A
. s the gl andenl arges,i t w i l l l os e i ts s y m-
metry.

F igur e 4 5 - 1 4 . P r o s t atitis.T h e p r o sta teis sym m e tr ica llye n -

larged,but the ventralmarginof the glandis slightlyiregular (black
arrowheads),and there are slightlysonolucentzones in the dorsal
portionof the gland(whitearrowheads). Sucha mottledappearance
l f p r o s t a t i t ibs u t ca n b e se e nwith n e o p la sia
is t y p i c a o a s we ll.

Figure 45-15. This rough irregularcavity (blackarrowheads)

within the prostate is easily detected sonographically. Such
cavitiesmay representsmall cysts or abscessesbut they are
al soseenw i th neopl asi a.
S ucha fi ndi ngw arrantsa n ul tras ound-
gui dedbi opsyof the gl and.
 The ProstateGland 6(ll

Figure 45-16. Transversesonographicimageof the prostate.The marginsof

t he g l a n d a r e d i f f i c u l tto d e fin e ,T h e r e is a m a r ke d lym o ttled patternto the
prostate.Some areasare very hyperechoicand others almost sonolucent.Such
a patternis characterjstic of neoplasiabut can be seen in severeprostatitjs.

sulting in a mixed echogenic pattern that causes asymmetrical
enlargement ofthe prostate. This is the typical sonographic pattern
of advancedsolid tumors that is seenin many organs (Fig. 4S:q.
When seen early, prostatic neoplasia may cause a single bright
focus within one area of the gland, and the gland may or may nor
be distorted (Fig. a5-17).
A definitive diagnosis of any given prostatic diseaseshould not
.
be made on the basis of sonographicfindings alone.35 An ultraso_
nographically.guidedbiopsy should be performed to support the
sonographicdiagnosis.In dogs with suqpectedneoplasia,biopsies
should be taken of the primaiy lesion of interest urrd of th. oth",
quadrants of the gland.

Figure 45-17. There is a single hyperechoiclocus (btack

and white arrowheads)wilhinthe prostate.Such lesionsmav
be b e n i g nc a l c i t i c a t i osne co n d a r ryo p r o sta titis
b u t a r e tvp ica l
of carcinomain situ and, therefore, indicatethe need for
a broosv.
 602 AN IN /A L S
A B DO M E N- C OMP AN IO N

References
l. Finco DR: Diseasesofthe prostate gland ofthe dog. In Morrow DA (ed): Current
Therapy in Theriogenology. Philadelphia, WB Saunders, 1980.
2. O'Shea ]D: Studies on the cmine prostate gland: 1. Factors influencing its size
and weight. J Comp Pathol 73:321, 1962.
3. Metten S; A morphologic study of benign prostatic hlpertrophy in the dog
ldoctoral dissertationl. Fort Collins, Colo, Department of Anatomy, Colorado State
University, 1978.
4. Barsanti IA, Shotts EB Jr, Prasse K, et al: Evaluation of diagnostic techniques for
cmine prostate disease.J Am Vet Med Assoc 177:160, 1980.
5. Gricne TP, Johnson RG: Diseases of the prostate gland. In Ettinger SI (ed):
Textbook of Veterinary Internal Medicine: Diseases of the Dog and Cat, 2nd ed.
Philadelphia, WB Saunders, 1983.
6, Rogers KS, Wanrschek L, Lees GE: Diagnostic evaluation of the canine prostate.
Comp Small Anim 8:799, 1986.
7. Zollron GM, Gricner TP: Prostatic abscess:Surgical approach J Am Anim Hosp
Assoc 14:698,1978.
8. Barsanti JA, Finco DR: Canine bacterial Prostatitis Vet Clin North Am 9:679' 1979.
9. Kornegay J: Canine prostatic disease.SW Ver 26:257, 1973.
27. Christensen GC: In Evans HE, Christensen GC, Miller ME (eds): Miller's Anatomy
ofthe Dog, 2nd ed. Philadelphia, WB Saunders, 1979, p 565.
28. Franks LM: The spread of prostatic carcinoma to the bones. ] Pathol 65:91, 1953.
29. Root CA: Urethrography. In Ticer IW (ed): Radiographic Techniques in Veterinary
Practice, 2nd ed. Philadelphia, WB Saunders, 1984, p 387.
30. Johnston GR, Feeney DA, Osborne CA, et al: Effects of intravesical hydrostatic
pressure and volume on the distensibility of the canine prostatic portion of the
urethra. Am I Vet Res 46:748. 1985.
31. Ackerman N: Prostatic reflux during positive contrast retrograde urethrography
in the dog. Vet Radiol 241251,1983.
32. O'Brien T: Normal radiographic anatomy of the abdomen. In O'Brien I Biery
DN (eds): Radiographic Diagnosis of Abdominal Disorders in the Dog and Cat:
Radiographic Interpretation, Clinical Signs, Pathophysiology. Philadelphia, WB Saun-
ders, 1978,p 9.
33. Cartee RE, Rowles T: Transabdominal sonographic evaluation of the canine pros-
tate. Vet Radiol 24:156,1983.
34. Stowater JL, Lamb CR: Ultrasonographic features of paraprostatic cysts in 9 dogs.
Vet Radiol 30:232, 1989.
35. Hager DA, Nyland TG, Fisher P: Ultrasound-guided biopsy of the canine liver,
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?

25. O'Brien T: Abdominal masses. In O'Brien T, Biery DN (eds); Radiographic

Diagnosis of Abdominal Disorders in the Dog and Cat: Radiographic Interpretation,
10, Prostate tumors frequently contain (mineralization, gas, fat)
Clinical Signs, Pathophysiology. Philadelphia, \AIB Saunders, 1978' p 85 that can be visualized sonographically.
J Am Anim Hosp
26. McClain DL: Surgical treatment of perineal prostatic abscesses.
Assoc l8:794, 1982. Answers begin on page 727.
 CHA P T E B

46
The Uterus, Ovaries, and Testes
. Daniel A. Feeney . Gary R. Johnston

f Uterus Normal imaging findings

Nonpregnant animal. The uterine body and horns cannot be
lmaging procedures
seenin surveyradiographsin the normal dog or cat unlessenlarged
The major applications of survey radiographsto diseasesof the or when the animal is pregnant.3The normal uterus is tubular,
uterus lie in conlirming that a palpableabdominal mass is consis- about 1 cm in diameter, and is located in the mid- and caudal
tent with an enlargeduterus,or in identifing an enlargeduterus in abdomen,witl.r the uterine body betweenthe colon and the blad-
a bitch that is difficult to palpate.Other usesfor surveyradiographs der.rThe radiopacityof the normal nongravid uterus is that of soft
include assessment for the purposesof determining (1) fetal skele- tissue,and it usually cannot be differentiatedfrom small intestine
tons (i.e., number and degreeof mineralization), (2) progressin on survey radiographs.The ultrasonographicfindings in the nor-
variations of uterine size both during pregnancy and in disease mal uterus were describedunder Imaging proceduresin the section
statessuch as pyometra,and (3) to a limited degree,fetal viability, on Uterus.
based principally on the absenceof findings consistentwith fetal Pregnant animal. The size, shape,and opacity of the canine
demise.An understandingof possibleconditions affectingthe fe- uterus during pregnancy vary with the breed, the number of
male genital tract is essentialto the interpretation of the radio- fetuses,and the stage of gestation. The fetal development and
^,^-L:^ C-l:-^^ | 7 radiographic appearanceof the uterus during gestationhave been
5r 4PrrrL rrrlurrrSJ.
Adequate attention must be paid to techr-ricalprocedures to r(,2r but a brief summary follows.
describedin detail elsewhere,,,,s,
ensuremaximal radiographiccontrastbecausethe uterus in disease In general, uterine enlargementis detectableradiographicallyat
states and without the presenceof skeletal structures must be approximately30 days after ovulation.,'The circumferenceof the
differentiatedfrom the bladder,bowel, and other nonspecificab- uterine horns is then reported to be about l0 or ll cm.rsSpherical
dominal masses.Unlessthe patient is critically ill, ideal preparation enlargementsat the location of the gestationalsacsare identifiable
includeswithholding food for 24 hours and administeringenemas in the uterus between30 and 40 daysafter ovulation.6The circum-
to evacuatethe colon at least 2 hours before radiography.sRadio- ferenceat the sphericalenlargementis then approximately 10 to
graphic techniqueis also important when the early mineralization 15 cm.'n The uterus subsequentlybecomessmoothly tubuiar and
of fetal skeletonsis assessed because,in the presenceof a large has been described as sausage-shaped at about 38 to 45 days
uterus,early fetal mineralizationmay be maskedby poor technique. after ovulation(';the circumferenceof the uterine horns is then
Abdominal compressionhas been suggestedas a possiblemeans approximately12 to 17 cm.r8Early fetal mineralization is identifi-
by wl.rich the colon, uterus, and bladder may be differentiated able by survey radiographsat or beyond 45 days after ovulation.,'
radiographically.8 The usefulnessof this techniqueis basicallylim- A near-termpregnancyin a normal bitch is shown radiographically
ited to patients in whicl-rthe uterus is not massivelyenlargedand in Fieure 46-3.
can be aligned betweenthe color-rand urinary bladder by using a
compressiondevice-eitl-rer a plastic paddle or a wooden kitchen
spoon. An exampleof the type of separationthat can be achieved
is shown in Figure 46-1.
Ultrasonographyis useful for tl.rediagnosisof pregnancyin the
bitch as well as for confirmation of fetal viability.'' 7 It is also
valuablein assessing a mildly enlargeduterus to determinewhether
the contents are fluid, as in pyometra; gestationalsacs,indicative
of pregnancy;or a mass,suggestiveof neoplasia.T,e 15
Interpretation of two-dimensional ultrasonographyis based on
tl-reconceptsdescribedin Chapters2 and 42. In the normal anes-
trous bitch, the uterus is a tubular structure that is about the size
of a collapsedsmall ir-rtestine. However, it lacks the central echo-
genic stripe seen in the submucosal and mucosal layers of the
intestine.In a bitch in estrus,a limited echogenicstripe is seenin
the areaaround the collapseduterine lumen. Any fluid seenin the
uterus must be consideredto be abnormal. This mildly echogenic
stripe representsthe developmentof the endometrium in response
to the hormonal stimulation related to estrus.The normal uterus
can be difficult to find, particularly in a bitch with gas accumula-
tion in regional bowel structures.The normal uterus is easiestto
locate betweenthe urinary bladder and the colorectaljunction. An
exampleof normal uterus in an anestrousbitch is shown in Figure
46-2. Doppler ultrasound techniques have been applied to fetal
and maternal assessments in the pregnantbitch, but are not consid-
Figure 46-1. Lateralview of the caudalabdomen.Localcompressionwas
ered to be a routine part of a general work-up of either the appl i edby usi nga w oodenspoonduri ngradtography.N ote the s eparati on
of
pregnant or the nonpregnantbitch or queen. the col oni c), uterus(u),and uri narvbl adder{b).

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
those ofthe dog. The feline uterus during gestationis describedin
considerabledetail elsewhere,2lbut a brief summary follows. In the
pregnant cat, radiographically detectable uterine enlargement oc-
curs at approximately 25 to 35 days of gestation. Fetal mineraliza-
tion is identified at approximately 36 to 45 days of gestation and
progressesbeyond this time.
The location of the pregnant uterus in both the dog and the cat
is in the mid- to caudal ventral abdomen at mid- to late gestation.
The enlargement of the uterus at this site causes cranial and
somewhat dorsal displacement of the small intestine, with dorsal
and lateral displacement of the descending colon and some degree
of ventral compressionof the urinary bladder.8
i' A normal pregnancy can be detected sonographically in dogs
and cats at gestational age slightly less than 20 days. However, in
our hands, the confidencehas been limited, particularly in bitches
or queens presented for follow-up to breeding intervention from
past infertility problems, or in those with unknown breeding or
heat dates. Although details are availableelsewhere,'o'rr' 13'ra the
following is a working assessmentof pregnancy focused on the
dog. The earliesttime we suggestultrasonographicassessment of
pregnancy is between 25 and 30 days gestational age. The closer to
30 days gestational age, the more likely a clearly defined heartbeat
will be detected.A common problem is assessment too early in the
gestation (particularly when the breeding dates are uncertain),
which usually yields equivocal results. Although small cyst-like
Figure46-2. Sagittal ultrasonogramof a normalanestrous
uterlnebody
segment(arrows) in a bitch.Notethe tubularappearanceandthe lackof
the centralechogenicstripeassociatedwith normalbowel.
gestational sacs can be found around 20 days gestational age, a
true gestational sac is easily identified in the 25- to 30-day range
(Fig. a6* ). In the 30- to 40-day range of gestationalage, the
conceptus begins to take on shape (e.g., not just a disc or a
rounded aggregate).After 40 or so days, evidence of mineralization
can be found and identification of the stomach, urinary bladder,
heart, and great vesselsbecomesprogressivelyeasierwith time (Fig.
46-5). In our experience,the radiographic assessmentof distal
limb bone development is still the best predictor of late-term
gestationalage.u,tt However,the ultrasonographicassessment is the
best for assessingfetal viability and well-being.ra We use the rule
of thumb that the fetal heart rate should be 1.5 to 2.0 times that
of the bitch or queen. Slow heart rate raises concern about fetal
distress.A searchfor feti must be made in an organized fashion by
checking both horns and the body. As for late-term gestational
aging, survey radiographs have been more accurate in our hands
for counting feti than has ultrasound.
Abnormal imaging findings
Number, Absenceof one of the horns in a normally bicornuate
uterus has been reported,22 but this is rare.
Sr2e. Generalized uterine enlargement in the absence of fetal
mineralization may be suggestiveradiographically of a number of
diseasesin addition to the early phasesof normal pregnancy before
fetal mineralization. Differential diasnosesthat should be consid-
Figure 46-3- A normalpregnancy,nearterm, in a bitch (lateralview). ln
the fetuses,note the mi neral i zati on
and al i gnmentof the s k ul l bonesas
w el l as the arrangement of the cervi caithroughl umbarvertebraeand the
pel vi sw i th the appendages.

Figurc 464. Ultrasonogramof an early pregnancy{approximately25
days gestationalage)in a dog. The fetal vesicleis within the cursors.
ered under these circumstancesinclude early pregnancy and possi-
bly pseudopregnanct'{' "; pyometra, hydrometra, and mucome-
uterine torsion38,2s'26'
tra3-8,23,24' uterine entrapment2T; and uterine
adenoinyosis.'z8,'zeRepresentativeexamples of diffuse uterine en-
largement are shown in Figures 46-6 and 46-7.
Generalizeduterine enlargement in the presenceof fetal mineral-
ization is suggestiveof pregnancy,but the possibility of torsion of
the pregnant uterus should not be excluded. Clinical signs and
history must then be used to differentiate these possibilities.
Localized uterine enlargement may be suggestiveof a number of
diseases, including neoplasia3,30; cystic endometrial hyperplasiaz3o;
localized or loculated pyometra, hydrometra, or mucometra2a;uter-
ine stump granuloma or abscessT,8'3t; cystic uterine remnant32;and
uterine adenomyosis.28' 2e Focal uterine body enlargement con-
firmed as a uterine stump granuloma with urinary bladder invasion
and a fistulous tract draining into the flank are shown in Figure
46-8.
Location. The normal location of the uterus in the caudal
ventral midabdomen has been discussed,and its detection as well
as location and effect on adjacent organs is highly dependent on
its size.3,8Herniation of the uterus through discontinuitiesin the
abdominal wall, including the inguinal ring, may occur and may
be congenitalor acquired.'''z7 It is also possiblethat thesehernia-
tions may occur during pregnancy. An example of uterine hernia-
tion into the subcutaneoustissuesvia the inguinal canal is shown
in Figure 46-9. This uterus was in the stagesof gestation prior to
fetal mineralization.
Radiopacity. The normal nonpregnant and early pregnant
uterus is of soft-tissue or fluid radiopacity.3t Other uterine condi-
tions that also have soft-tissue radiographic characteristicsare pyo-
metra, hydrometra,mucometra, and uterine torsion.3-8,2s,26 As was
previously mentioned, history and clinical signs are necessaryto
differentiate these possibilities. Gas within the uterus is generally
Figure 46-5. Ultrasonogramof a late second and early third trimester
p r e g n a n c y( + 4 0 d a ys g e sta tio n aal g e ) in a b itch .T h e sp ine i s cl earl y
v i s i b l eb
, u t t h e r ei s a lm o stn o sh a d o win qd u e to lim ite dm in e ral i zati on.
The Uterus,Ovaries,and Testes 6()5
indicative of either fetal deathl 5' 6 or ischemia due to uterine
torsion.2 In both instances, the qas is due to devitalization and
breakdown of the tissues.An exairple of an emphysematousfetus
is shown in Figure 46-10. Be careful that there have been no
traumatic attempts at catheterization of the cervix wherein gas
could have artifactually been introduced and overinterpreted as
evidence of intrauterine disease.The other possibility is that a gas-
forming organism within an abscessof the uterine stump inlhe
neutered patient may cause focal accumulation of air, bu1 this is
highly unlikely.8
Mineralization within the uterus is usually indicative of fetal
skeletons,but it is imperative that the alignment of the structures,
such as vertebrae, ribs, and limbs, and the shape and alignment of
skull bones be assessedto differentiat. a tudiostaphicillv viable
fetus, a dead fetus, and a mummified fetus.i u in eenerai, radio-
graphic evidenceof axial or appendicularskeletalmilalignment or
collapseof the skull bones is suggestiveof fetal death. Overlap and
apparent compression of the structures into a smaller than expected
spaceis more suggestiveof mummification than of a recent liistory
of fetal death. An example of a mummified fetus is shown in
Figure 46-1 1.
If the fetal skeleton appearsto be tightly curled, is more obvious
than expectedwhen surrounded by uterus, or is not associated
with a tubular uterine radiopacity or its expectedlocation, the
possibility of ectopic pregnancy should be considered.3.-.s perito-
neal effusion may complicate the assessmentof the uterine bound-
ar.i9s
!n these patients and may further confuse the diagnosis
with the possibility of acute uterine rupture rather than eitopic
pregnancy.'3'3a Ultrasonographyis of value in this situation.T,rs
Function. Dystocia may be due to both maternal and fetal
factors.36Radiographs are of minimal value in determining the
maternal factors, such as uterine contractilitv, other than for assess-
ment of the size relationship between the ietus and the maternal
 606 A N IMA L S
A B DO M E N-C OMP AN IO N

tiirltl

Figure 46-6. tale"al (A) and ventrodorsal (B) radio-

graphs of a patlent with a tubular,coiled, soft-tissue
structurei n the caudalabdomenthat extendsi nto the
pel vi s (arrow headslThi . s i s a moderatel ydi stended
uterus,as found in pyometra,C Lateralview of a patient
w i th a caudoventral abdomi nal massthat occupi esabout
60% of the abdomi nal cavi ty.D i spl acement
of the vi scera
I i s consi stentw i th uteri neenl arqement,

Figure 46-7. Transverseultrasonogramof the left uterine horn in a

bi tch that i s fi l l edw i th compl exfl ui d.Thi s i s typi calof what i s s een i n
canlneDvometra.
 The Uterus,Ovaries.and Testes 6(07

Figure 46-8. Lateralview after excretoryurographyand left-flank

fi s t u l o g r a p h yA. d r a in in gtr a ct in th e le ft fla n k in le cte dwr th contrast
m e d i u ml e a d st o a s o ft- tlssu e m a ss,wh lch d isp la ce th s e u r narybl ad-
d e r v e n t r a l l ya n d i n de n tsit d o r sa lly.On ly th e r ig h t kid n e yand ureter
a r e i d e n tf i e d . R a d i olo g ic
d ia g n o ss: p r o b a b le
u te r in estu m p granul oma
w i t h c h r o n i co b s t r u ctioonf th e le ft u r e te rT. h e d ia q n o sis
wa s coni i rmed
at laoarotomv.

pelvic canal. Radiographymay be helpful in assessingone of the
fetal factors-positioning relative to the maternal peivic
canal-thus providing additional evidencefor the necessityof ce-
sareansection (Fig. 46-12). If there is no fetus lodged in the birth
canal, another considerationis uterine inertia. Survey radiographs
may also be of value in the postpartum bitch to determine the
possibility of a retained fetus, but routine follow-up radiography
of every pregnancyis not indicated.
I Ovaries
lmaging procedures
Survey radiographshave limited applicability to the ovaries.Be-
cause ovaries are the basis of reproduction, exposureto ionizing
radiation should be minimized. The major applicatior.rof survey
radiographsto the ovary is that of identifying a massnot palpable
at physical examination, or further localizing an abdominal mass
to the ovary. On the basis of location, displacementof adjacent
organs,and radiographic opacity,the organ of origin of the mass
may be determined.nSurveyradiographsare of considerablevalue
in differentiatingovarian,splenic,and renal masses.The limitations
are that normal ovaries cannot be visualized and the internal
architectureof ovarian massescannot be assessed by radiography
unlessmineralizationis present;such mineralizationis uncommon.
Excretory urograp\ may be of assistancein assessingovarian
massesby assistingin identification of and distinction from the
ipsilateral kidney. Excretory urography may also be helpful to
determine the degreeof renal displacementand to separaterenal
parenchyma from that of the ovary if the mass has not resulted in
ventral migration of the ovary ventrally into the abdomen away
from the kidney.
Another techniquethat is extremelyvaluablein assessing intra-
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,
mination of ovarian activity and staging of ovarian masses.The
anestrousovary in the bitch and the queen has folliclesin the early
stagesof development (Fig. 46-13). It may also contain complex
or echogenicareasindicative of corpora hemorrhagicaor corpora
lutea. As estrus approaches,selectedfollicles become dispropor-
tionatelyiarger.The use of ultrasound to determineprime breeding
time has not become a routine procedurein the bitch and queen
as it has in the large domesticspecies,however.For further details,
readersare directedto References12 and 13.
Normal imaging findings
The normal ovaries,located just caudal to the kidneys, are not
(' The
seen radiographically.'z' ovaries are not, however, functionaliy
retroperitoneal as are the kidneys, and ovarian massesgravitate
ventrally without extensiveventral displacement of other abdomi-
nal viscera,such as that causedbv a renal mass.37

Figure 46-9. Lateralview of a bitch in midterm pregnancywith an inguinal

m a s s .T h e t u b ua r s oft- tissu eo p a cityr e p r e se n tinthg e u te r usextendsi nto the
su b c u t a n e o u p
s e r - i n g u in atissu
l e s.Ra d io lo g tc
d ia g n o sts:ingui nalherni acon-
taininga portionof dilateduterus,probablysecondaryto pregnancy.

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

Figure 46-10. Close-uplateralview of the ventralabdomen.Thereis a

moderateJymineralized
fetuswithinthe soft-tissue
uterineshadow.Thereis,
however,gassurrounding
thefetus.Radiologic
diagnosis:
emphysematousfetus.

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

Figurc 46-11. Lateralview of a previouslypregnantbitch. An irregularly

d a s sw i t h s o m e e vid e n ceo f sku lla n d tu b u la rb o n e sis vi si bl eand
m ine r a l i z em
is locatedoutsidethe intestinaltract and in a regionconsistentwith that of the Figure 46-12, Ventrodorsalview of a small-breedbitch in dystocia.Note
ut eru s R m u m m ifie dfe tu s.T h e d ia g n o sis
. a d i o l o g idci a g n osis: wa s confi rmedat the transversepresentationof the enlarged,but as determinedradiographically,
surgery. vi abl efetus.S urgi cal vi abl esi ngl efetus (w hi chsubse quentldi
di agnosi s: y ed).
 The Uterus.Ovaries.and Testes 6(19

Figurc 46-13. Sagittaultrasonogram of a normalanestrous ovary

(withinthe cursors)
in a bitch.Notethe subtiefolliclesof fairlyuniform
stzebrrowd.

Second,the determination must be made that the mass is ovary,
often by exclusion of association with other regional structures.
Locating some small follicular structureson the perimeter is useful
because the anestrous ovary can be difficult to locate (see Fig.
46-13).In that circumstance,what the mass is not attachedto or
an extensionof must be determined,with ovarian mass being the
rule-out based on location. Third, becausemany ovarian masses
are malignant,4o-43 the concern is whether or not local or regional
spreadhas occurred.The searchfor peritonealseeding,abdominal
fluid collections, and noduies in any other abdominal organs is the
goal to appropriately stage this potential malignancy. Fourth, be-
cause malignant versus benign ovarian masseshave no specific
sonographic architecture to differentiate between them, about the
only architectural characteristic that can be comfortably assessed
are follicular cysts. A fluid-filled cavity with no internal echoes;
smooth, thin walls; and good echo enhancement beyond it is most
likely to be a benign follicular cyst ifthe clinical signs are consisrenr
with this.
Radiopacity. Ovarian cysts and most ovarian neoplasms are of
soft-tissueopacity.tt'a0Occasionally,ovarian neoplasmsmay con-
tain mineralizedareas,including those with the opacity of bone or
tooth enamel.Such massesare usually benign teratomas(dermoid
cysts),38'a0but malignant teratocarcinomashave also been reported
to contain mineralization.a2 On the basis of this assessmentand
the vast difference in prognosis for these two types of tumors, it is
ill-advisedto baseprognosison the presenceof mineralization.
Consideration. It is important to be aware of the possibility of
intersex conditions, including the true and pseudoiermaphro-
dite.44'4sComplex anomaliesencompassing
the entire genital tract
and involving the urinary tract should be considered in patients
with other intra-abdominal abnormalities or combined urinary
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
and ultrasonographic evaluation may be of assistancein analyzing
the anomaly, it is often necessaryto remove the anomalous tissue
and then to evaluateit by dissection and histologic examination.T'ls
I Testes
lmaging procedures
Survey radiographs have limited applicability to the intrascrotal
testes. Radiographs are, however, of value in the assessmentof
abdominal masses,which include neoplastic transformation of an
intra-abdominal testicle. In addition, testicular exposure to the
mutagenic effects of ionizing radiation should be limited. An addi-
tional method that does provide information on the intrascrotal
and intra-abdominal testicular architecture is ultrasonography.'u-tt
The testicle, particularly in the dog, is relatively easily scanned as
long as it is in the scrotal sac. However, retained but normal
testiclesare at best diffrcult and often impossible to find if they are
intra-abdominal owing to masking by bowel gas. Testiclesbetween
the inguinal ring and the scrotal sac can be identified, if an
organizedand tedious searchis implemented.The normal testicle
has an echogeniccapsule(tunica albuginea)and a uniform paren-
chymal echotexturesimilar to that of the spleen (Fig. 46*15). In
the longitudinal center of the testicle, the mediastinal testes (rete
testes)can be found. This is a useful architectural structure to help
determine if there are parenchymal disruptions that have changed
the regional echotexture(e.g.,an isoechoicmass).The epididymis
is usually hypoechoic to the testicle and lies approximately dor-
somedial to the testicle. It has a more coarse echotexture than the
testicle, but this is a subjective assessment.Any fluid seen in the
scrotalsacis consideredabnormal,and a searchfor its causeshould
l,
be undertaken. Doppler techniques allow visualization of the arte-
rial and venous flow in the testicle and the regional vasculat
structures. If available, this is a useful tool in the noninvasive
assessment of testiculartorsion.
Normal imaging findings
Becausethe testicles, epididymis, and scrotum are all soft-tissue
structures, radiography is of minimal value in the evaluation of
these organs in small animals. The accessibility of the scrotum to
visual and digital inspection further minimizes the usefulnessof
radiography. Radiography may occasionallyprovide some informa-
tion on the opacity (such as mineral and air) of an abnormality
detectedby palpation. Ultrasonography is of assistancein noninva-
sively assessingthe internal architecture of the testicle and epididy-
mis, as well as the nature of scrotal enlargement.nu'n"-''
The normal sonographic appearanceof the testicle is described
earlier in this chapter.
Abnormal imaging findings
Detailed discussion of the embryogenesisof the testes,gubernacu-
lum, and scrotum is beyond the scope of this book; for further
details, the reader should consult References52 and 53. As with
ovarian diseases,intersex anomalies must be considered. These
anomalies may be evaluatedwith the use of contrast procedures of
the lower and upper urinary tract, as well as with ultiasonography,
although the final diagnosis is usually determined surgically and
microscopically.44' s'?With this preface,most of the following discus-
sion deals with sequelae of cryptorchidism amenable to radio-
graphic assessment.
Intra-abdominal testicles that are of normal dimension usually
cannot be identified radiographically. If the intra-abdominal testicle
enlarges,however, the following considerations may apply.
Size and shape. To be detected radiographically, the enlarged
intra-abdominal testicle must be two or more times the diameter
of the normal small intestine. \A{hen such a structure is identified,
it must also be differentiated from other soft-tissue structures in
the abdomen, such as fluid-filled bowel, bladder, spleen,and possi-
bly the prostate gland. In general, the radiologic consideration of
the mass as an intra-abdominal testicle results either from the
knowledge that only one testicle was descended or identified at
castration, or by the fact that the mass cannot be associatedwith
any other organ in a male patient. The shape of the enlarged,
and probably neoplastically transformed, intra-abdominal testicle
is usually fairly symmetrical, with varying degreesof surfaceirregu-
larity.
Number and radiopacity. Usually only one of the testicles is
responsible for the abdominal abnormalities in a given patient,
evenifboth testiclesare intra-abdominal.The radiographicopacity
of intra-abdominal testicles is usually that of soft tissue, and no
specificity may be assignedto the identification of calcific opacity
within these masses;such an opacity is most likely to be dystrophic
calcification rather than suggestiveof teratoma and teratocarci-
noma, as in the bitch.
Location, Intra-abdominal testicles,when identified radiograph-
ically as an abdominal mass,usually lie somewherein a parasagittal
plane between the caudal pole of the ipsilateral kidney and the
inguinal canal.The authors'experiencesuggeststhat thesetesticles
usually gravitate to the ventral abdomen as they enlarge, causing
dorsal and lateral displacement of the small intestine and possible
indentation or caudal displacement of the urinary bladder. An
example of a neoplastically transformed intra-abdominal testicle is
shown in Figure 46-16. Testiclesmay be identified in the inguinal
canal or subcutaneousstructures ofthe inguinal region. Subcutane-
ous soft-tissue massesin this region in a male dog may be identified
radiographically, but differentiation from lymph node, subcutane-
ous tumor, or another nonspecific mass requires ultrasonographic
Figure 46-15. Sagittalultrasonogram
of a normalcaninetesticle.Note
the mediastinumlestes (arrow).
 The Uterus,Ovaries,and Testes 6l I

Figure 46-16, Lateralradographof a ma e dog with an abdominalmass

an d o n l y o n e p a l p a b e,d e sce n d e dte sticle .T h e a b d o m in am l ass i n the
c au d a lm i d v e n t r aal b d o m e nis a p p r o xim a te ly fo u r to six tir n es rne srze
of th e k i d n e y s R. a d i o gr a p hdicia g n o sis: we ll- cr r cu m scn b ine dtr a-abdomi nal
ma s s ,p r o b a b l ya r e t a i ne din tr a - a b d o m inte
a sticle
l T. h e d ia o n o si w
s as con-
firmed at laDarotomv.

assessment (Fig. 46-17) and probable microscopicexamination of Intrascrotal testicle

a fine-needleaspirate. Size and shape are the major featuresused to assessthe intrascrotal
Consideration. An intra-abdominal mass identified in a male testiclefor potential abnormalities.Symmetricalenlargementof the
dog fitting the size, shape,and location criteria describedearlier testicle or hemiscrotum is suggestiveof orchitis,s6f,ydrocele,+g, rt
must be differentiatedfrom other intra-abdominal organs,includ- intrascrotaltesticulartorsion,ae,sa and nonspecificvascuiarabnor_
ing the spleen,bladder, cecum, and prostate gland; a nonspecific malities.ssObservation of the testiculu. and spermatic cord
mesentericmass;and a massoriginating within the intestinaltract. at scrotal exploratory surgery is the most -ri, definitlve means of
Ultrasonographicexamination can be valuable in this differentia- differentiation among the scrotai contents and is not associated
tion.aeFine-needleaspirationbiopsy and laparotomy are the alter- with the known geneticsequelof ionizing radiation to the opposite
nativesworthy of consideration. testicle. Asymmetrical enlargement of the intrascrotal tesiicle is
The mass,which is possibly testicle,may representa neoplasti- suggestiveof neoplasia,r0 varicocele,ae hematoma,abscess, and epi_
cally transformed,retainedtesticlea0or torsion of an intra-abdomi- didymitisss; differentiation of these possibilities may be facilitaied
nal testiclewithout neoplastictransformation.s0. saDifferentiation by information from the history and fine-needleaspirationbioosv.
betweentheseprocessesis basedon the history, abdominal palpa- As was mentioned previously,an additional means of nrr.riirr*
tion, and reproductiveand cutaneousmanifestationsof endocrine the internal contents of the scrotum, includinx the testicle, i!
abnormalities,that is, feminization, associatedwith neoplastictes- u l t r a s o n o g r a p h y . '" - s1rn '. m e t h o d p e r m i l s i d e n " t i fi ca ti o o
n f th e
ticular tissue. sourceof scrotal enlargementas to testicle,fluid retentron,associ-

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
architecture of the mass. An example of a focal testicular mass is
shown in Figure 46-18.
I Abnormal intra-abdominal
I findings related to the uterus,
I ovaries, and testes
Unexplained intra-abdominal calcific opacities may be related to
previous uterine rupture or ectopic pregnancy and subsequent
mummification of the involved fetuses.Careful radiographic scru-
tiny of the character of the calcified intra-abdominal massesand
the possibleuse of serial radiographsto assessreproducibility of
the location are indicated. Occasionally,ingestion of an intact body
of a puppy or other small mammal by the patient may complicate
the diagnosis of intrauterine fetal calcification, intra-abdominal
ectopic pregnancy, or fetal mummification.
Variations in abdominal contrast may be somewhat nonspecific
in that there are numerous causesof accumulationof abdominal
fluid and free intraperitoneal air. The presenceof abdominal fluid,
however, especiallyif the patient has intestinal displacement (based
on the intestinecontaining gas,so it can be recognized)consistent
with an enlarged uterus, may be suggestiveof uterine rupture with
subsequenthemorrhage,ruptured pyometra, or hemorrhagefrom
uterine torsion. Free intraperitoneal air in such patients, especially
in the presenceof intrauterine (perifetal) or intrafetal air, is highly
suggestiveof uterine rupture and fetal death.
Figure 46-18. Sagittalultrasonogramof a testiclein whicha hypo-
echoicmass(withinthe cursors)
canbe seen.Sonographic is
appearance
neither
specific
fortumorcelltypeor fordifferentiation versus
of malignant
benignlesions.
Peritoneal effusion, which may occur from a wide variety of
causes,may result from peritoneal seeding and diffuse metastasis
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-
sions should at least be considered as differential possibilities in an
intact bitch.
Medial iliac lymphadenopathy may be identified in patients with
testicular diseaseand is most suggestiveof metastasiss6,sT or exten-
sion of an inflammatory process. Lumbar vertebral osteomyelitis
and discospondylitis have been reported in patients with inflam-
matory diseasesof the testicle, including, specifically,infection due
to Brucella canis.s8
One final consideration of genital imaging is the vagina. A1-
though this organ is usually accessiblevia direct visualization facili-
tated by various endoscopic devices,there are times when contrast
radiographic imaging is the only method of viewing the area cranial
to the vestibule. Positive-contrast vaginography is the retrograde
filling of the vestibule and vagina.seVaginography is performed
using sterile, iodinated contrast medium diluted to about 150 to
200 mg of iodine/ml. The contrast medium is injected through a
balloon catheter that has been placed just inside of the vulvar lips
using appropriate sedation. Retrograde injection is performed until
mild resistance to injection is met. A lateral view is made to
determine the degree of filling. Retrograde injection is continued
if the vagina is not well distended. Overdistention may result in
expulsion of the contrast medium as a result of an abdominal
press. Vaginography may be used to localize vaginal or vestibular
Figure 46-19. Lateralview of a bitch duringretrograde,positivecontrast
vaginography.
Note the narrowingat the interfaceof the vestibuleand the
vagina(arrow).Radiographic
diagnosis:vaginalstricture.
 The Uterus,Ovaries,and Testes 613

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.
References
31. SpackmanClA, Caywood DD, JohnstonGR, et
al: Granulomasofthe uterjne and
1. England G: Infertility in the bitch and queen. In Arthur GH, Noakes DE, pearson ovarlan sturnps:A casereport. I Am Anirn Hosp Assoc
201449,19g4.
H, et al (eds): Veterinary Reproduction and Obstetrics, 7th ed. philadelDhia, WB
S a u n d e rs,l q g h , p 5 1 6 . 32. Franklin RT, Prescott JVB: Tenesmusand stranguria
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,
p 1263.
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
sertoli cell tumor. Vet Rec 106:144, 1980.
57. Simon J, Rubin SB: Metastatic seminoma in a dog. Vet Med Small Anim Clin
74:941,1979.
58. Henderson RA, Hoerline BF, Kramer TT, et al: Diskospondylitis in three dogs
infected with Brucella canis. J Am Vet Med Assoc 165:451, 1974.
59. Allen WE, France C: A contrast radiographic study of the vagina and uterus of
the normal bitch. I Small Anim Pract 26:153, 1985.
60. Gibbs PEC, Latham l: An evaluation of positive contrast vaginography as a
diagnostic aid in the bitch. J Small Anim Pract 24:531,1984.
61. Kyles AX, Vaden S, Hardie EM, Stone EA: Vestibulovaginal stenosis in dogs: 18
cases(1987-1995).J Am Vet Med Assoc209:1189,1996.
62. Root MV Johnston SD, Johnston GR: Vaginal septa in dogs: 15 cases(1983-1992).
I Am Vet Med Assoc206:50,1995.
63. Johnston GR, Osborne CA, Wilson JW, Yane BL: Familial ureteral ectopia in the
dog. J Am Anim Hosp Assoc 13:168,1977.
K Ouestions
l. The normal uterine body in a nulliparousbitch:
A. Is easily detectableon routine survey radiographs.
B. Is difficult or impossible to detect on routine survey radio-
grapns.
C. Usually lies between the distal colon and the urinary blad-
der near the midline.
D. Usually lies between the urinary bladder and the rectus
abdominis muscle on the midline.
E. Ban dC
2. The uterine horns in a bitch may:
A. Be indistinguishable from the small intestine, if normal,
B. Sometimes be distinguishable from the small intestine if
only mildly enlarged, provided the small intestine contains
gas.
C. Displace the kidneys cranially because both the uterine
horns and the kidneys are retroperitoneal.
D. Aa nd B
E. A, B, and C
3. Gas in the uterus can be the result of:
A. Fetal demise.
B. Uterine ischemia.
C. Vaginitis.
D. Intrauterine fetal growth retardation.
E. Aan dB
4. Which of the following survey radiographic findings are indica-
tions of late-term fetal death?
A. Malalignment of fetal structures
B. Collapse of the fetal skull
C. Tightly curled fetus
D. Emphysematousfetus
E. All of the above
5. Which of the causesof dystocia listed below can be diagnosed
from survey radiographs?
A. Uterine inertia
B. Fetus too large for maternal pelvic canal
C. Fetus lodged in the maternal pelvic canal
D. Fetus in a position such that it is blocking the entrance to
(or unlikely to pass through) the maternal pelvic canal
E. B, C. and D
6. An ovarian mass can:
A. Displace the bowel, particularly the colon, ventrally as can
be seen with retroperitoneal massesoriginating in the kid-
ney.
B. Migrate ventraliy among the small intestinal loops, if en-
larged.
C. Induce peritoneal fluid, if malignant and there has been
"peritoneal seeding."
D. A, B, and C
E. BandC
7. Mineralization of an ovarian mass as detected bv survev radi-
ography:
A. Is useful to differentiate malignant from benign masses
becauseonly benign massesundergo mineralization.
B. Is useful to differentiate malignant from benign masses
becauseonly malignant massesundergo mineralization.
C. Eliminates consideration of an ovarian cyst becausebenign
ovarian cysts never undergo mineralization.
D. AandC
E. None of the above
8. Intra-abdominal testes:
A. Are readily detected on survey radiographs, even if not en-
larged.
B. Are difficult to impossible to detect on survey radiographs,
unless quite enlarged.
C. Have a radiographically specific appearancewhen enlarged
and can be easily differentiated from massesoriginating in
the bowel, mesentery,or abdominal wall.
D. AandC
E. BandC
9, Acute testicular torsion:
A. Is readily diagnosedon survey radiographsbecauseof gas
in the scrotum.
B. Is readily diagnosedon surveyradiographsbecauseof min-
eralizationin the scrotum.
C. Is readily differentiated from other intrascrotal problems
such as hydrocele or mass using survey radiographs.
D. Cannot be diagnosed by survey radiographs and is best
defined using a combination of acute history of pain, sym-
metrical testicular enlargement at palpation, and, if avail-
able,Doppier ultrasonographyto assess blood flow.
E. AandC
10, The normal ovary:
A. Can have survey radiographically detectablemineralization.
B. Can be determinedas to its phasein the estrouscycleusing
survey radiographic techniques.
C. Can be easily identified on survey radiographs and can be
readily differentiated from the small intestine.
D. A, B, and C
E. None of the above
Answers begin on page 727.
 CHA P T E R
47
The Stomach
. Mary B. Mahaffev . Don L. Barber
I Anatomy
The stomachis a musculoglandularorgan that connectsthe esoph-
agusand duodenum. The cranial surfaceof the stomachis in close
apposition to the caudal surfaceof the liver. In the normal dog
and cat, the empty stomach usually lies cranial to the last pair of
ribs,r,'zbut it may extend slightly caudal to the costal arch. The
stomach lies in a transverseplane, primarily to the left of the
median plane.
The stomach is subdivided into the cardia, fundus, body, and
pyloric portions (Fig. 47-1).r The cardia is a small area at the
esophagogastric junction. The fundus is the dome or outpouching
from the left dorsal aspectof the stomach.The body is the middle
portion from the fundus to the pyloric portion and is the largest
portion of the stomach.The distal one third of the stomachis the
pyloric portion, which is further subdivided into the pyloric an-
trum and the pyloric canal. The pyloric antrum is the proximal
two thirds of the pyloric portion and is relativelythin-walled and
slightly expanded.The pyloric canal, the distal one third of the
pyloric portion, is more muscular and containsa double sphincter.
Additional landmarks of the stomach include the greater and
lesser curvatures and the angular incisure (notch)., The greater
curvature is the convex surfaceof the stomach that originates at
the cardia and extends caudoventrally around to the pylorus. The
lessercurvature is the concavesurfacethat originatesto the right
of the cardia and extendscranioventrallyto the pylorus. It is the
shortestdistancebetweenthe cardia and the pylorus. The angular
notch is the point of acute angulation of the lesser curvature,
located approximatelyat the junction of the body and the pyloric
antrum. The mucosal surfaceof the stomach is characterizedby
numerous folds or ridges called rugal folds or rugae.
I Radiographic examination
Preparation
Ingestawithin the stomach may obscuresome lesionsor simulate
other lesionsand thus createfalse-negative
or false-positiveresults.
Therefore,under ideal conditions, routine radiographic examina-
tion of the stomach should be performed on an animal that has
Cardia
Pyloric
canal
Pyloric
antrum
Body
Figure 47-1. Thedivrsions
of the stomach.
been fasted for 12 to 24 hours.r 5 Nonirritating cleansingenemas
may also be useful. This method of preparation allows for more
accurateevaluationof the stomachand also for contrast studies,if
needed.Howeveqfastingis not feasiblein many situations,and the
inability to fast the patient is nor a contraindicationfor abdominal
radiography. Additionally, there are exceptions to fasting because
patients with emesis or anorexia may not require fasting. Also,
fasting and enemasshould be avoided in patients with acute ab-
dominal disorderswherein time delays ari medically contraindi-
cated,or fluid and gas patterns in the bowel may be of diagnostic
rmportance.
Consideration of medications is also important. Many drugs
used for treatment of gastrointestinaldisorders or for chemical
restraint affect gastric motility and may causegaseousdistention
of the stomach.These preparationsshould be avoided or discon-
tinued for an appropriate interval before any contrast study is
undertaken.6-r{)
Radiographic technique
Survey radiographsmay be sufficient for diagnosingsome gastric
abnormalities. If contrast studies are deemid necessary,survey
radiographyof the stomachshould alwaysprecedecontraststudies.
Various radiographictechniquesur. nvalluLl. and include conven-
tional barium sulfate gastrography,low-volume gastrography,dou-
ble.-contrast
gastrography, pneumogastrography, gastrographyusing
iodinated contrast media, and gastric emptying studiesusing bar-
ium-food or radiopaquemarker-food mixtures.2, r,6,1r-21
For compieteevaluationof the stomach,four conventionalviews
may be necessary: the ventrodorsalview, the dorsoventralview the
right recumbent lateral view, and the left recumbent lateral view
Oblique views may occasionallybe of value to isolate or project
certain areasof the stomach,such as the pylorus.
I Normal radiographic findings
The radiograpl-ricappearanceof the normal stomach is variable
and dependson many factors,such as the species,breed, degreeof
gastric distention, volume and type of gastric content, position of
the patient during radiography, and whether contrast medium
was usecl.
The stomach is usually easy to recognizeby its location and
shapeand the content of gas,ingesta,or both. The entire stomach
may not be discernibleon survey radiographsif it is empty, or if
the gastricfluid content silhouetteswith the liver or other abdomi-
nal structures. As a general guide, on the lateral view, the axis of
the stomach from the fundus through the body and pylorus is
either perpendicularto the spine,parallelto the ribs, or somewhere
betweentheseangles(Fig. a7-2A). On the lateralview, the pylorus
gay be superimposed over the body or located slightly cranial to
the body. On the ventrodorsalview of the dog, the cardia,fundus,
and body of the stomachare locatedto the left of midline, and the
pyloric portions are located to the right of midline. The pyloric
sphincter is usually located in the right cranial abdominal quadrant
at about the level of the 10th or 11th ribs and is usually cranial to
the pyloric canal.2In immature dogs, the pylorus may be located
closerto midline than in adults.,,
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
spine, with the stomach appearing to run transversely across the
abdomen, making the angular notch difficult to identifr (see Fig.
47-28). The stomach may also have a U-shaped appearancewith
a more obvious angular notch and still be within its normal
location (see Fig. 47-2C). On the ventrodorsal view of the cat, the
stomach is more acutely angled with the pylorus located at or near
the midline (see Fig. 47-2D). Variations in the appearanceof the
stomach in the dog based on the shape of the thorax and cranial
abdomen, that is, breed conformation, have been described.t The
actual shape of the stomach also varies with the degree of gastric
distention becausedifferent portions of the stomach vary in their
distensibility.
One of the most important factors in the appearance of the
stomach is the position of the patient during radiography." The
relationship between the position of the patient and the radio-
graphic appearanceof the stomach is an important concept that
must be understood for accurate interpretation of radiographs and
for demonstration of some gastric lesions. Variation in appearance
of the stomach with different patient positions is caused by shifts
in fluid and gas distribution within the lumen of the stomach. The
stomach usually contains both fluid and gas, with the fluid being
either of water opacity or positive-contrast medium opacity. This
fluid and gas distribution varies with the position of the patient
becausefluid settlesdependently owing to gravity, and gas rises to
the highest part of the lumen. Gas and positive-contrast medium

are relatively easyto visualize on radiographs, whereasfluid within
the stomach may be more difficult to seebecauseit may silhouette
with other structures of similar opacity.
To explain the radiographic appearance of the stomach, the
stomach can be described as J-shaped and positioned in a trans-
verse plane in the cranial abdomen. Thus, as an example, with a
patient positioned in dorsal recumbency for a ventrodorsal view,
fluid within the lumen settlesdependently to the fundus and body
of the stomach. If enough fluid is present, the pyloric portion of
the stomach also fills. Gas rises to the uppermost portion, which
is in the pyloric antrum and the body near midline (Fig. a7-3).
Frgwe 47-3 is a computed tomographic cross-sectionalview of the
cranial abdomen at the level of the stomach acquired with the dos
in dorsal recumbency.Note rhe fluid opacity hlling most of thI
stomach, with the gas bubble floating near midline. With this
image as an example, it is possible to predict how the fluid and
gas would be distributed if the animal were rotated in 9O-degree
increments for a left recumbent lateral view, a dorsoventral view
in sternal recumbency, a right recumbent lateral view, and back to
a ventrodorsal view in dorsal recumbency. These variations in
appearanceof the stomach are further altered by the volume and
ratio of fluid to gas within the stomach. Examples of the appear-
ance of the stomach with various views are illustrated in Figure
47-4; theseviews were made with a vertically directed x-ray beam.
On the ventrodorsalview (seeFig. a7-M), gas is located in the
pyloric antrum and the body near midline. Fluid settlesto fill the
fundus, body, and pyloric portions of the stomach. Less fluid with
a larger volume of gas would fill additional areas of the stomach
with gas. If completely empty, the fundus and body may appear as
a soft-tissue mass on the ventrodorsal view. On a dorsoventral
view (seeFig.47-aB), gas risesto the cardia and fundus, and fluid
settlesdependently to fiil the pyloric portions and part ofthe body.
On the left recumbent lateral view (see Fig. a7-aC), gas rises to
the pyloric portion of the stomach, which is on the patient's right
side and is thus the uppermost point of the stomach. Fluid settles
dependently to the fundus and body. Occasionally, a gas pocket
may be trapped in the fundic region. In this position, the fundus
and body are well visualized with positive-contrast medium but
are more difficult to visualize if fiiled with fluid (Fig. a7-5A). On
the right recumbent lateral view (seeFig. 47-4D), gas rises to the
fundus and body, which are on the patient's left side and thus are
uppermost. With this view, the gas ii often more spread out to fill
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
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-
ph y l l . V e t R a d i o l 2 2 : 1 4 91,9 8 1.)
The Stomach 617
the fundus and body (see Fig. 47-58) and may not stand out as
discretely as on the left recumbent lateral view. In addition, fluid
settlesdepend€ntly to fill the pyloric portions and part of the body
of the stomach. In this position, the pyloric portion is well visuall
ized with positive-contrast medium. Occasionallx the pyloric an_
trum and distal part ofthe body may appear in survey radiographs
as a soft-tissue mass in the right recumbent lateral view (see
Fig. a7-sB).
The radiographic appearanceof the normal stomach is variable.
It is thus_important to recognizevariations that exist in the appear-
ance of the normal stomach and to understand how the appeaiance
of the stomach may be altered by factors such as the position of
the patient and the volume and ratio of fluid to gas within the
stomach. It is also important to be able to take advintage of fluid
and gas shifts within the stomach to visualize certain portions of
the stomach more clearly.
Rugal folds are not seenwell on survey radiographs. With posi-
.
tive-contrast gastrography,rugal folds are best seen at the p.iipt _
eral portions of the stomach, where they may be visualized endon
as regular, small, filling defects at the mucosal surface (Fig. 47-6).
If projected en face, rugal folds are not visible with -positive-
contrast gastrography unless the barium is well penetrated by the
x-ray beam, or the stomach has emptied much ofthe original dose.
Rugal folds then appear as relatively radiolucent, linear, filling
defects separatedby barium in the inierrugal spaces(Fig. a7-78i.
Double-contrast gastrography provides the moJt detailed evalua_
tion of the gastric mucosa and rugal folds.
Radiographic assessmentof rugal folds is usually subjective.
_
Rugal folds vary in size and number,t 2r and the appearance of
rugal folds is dependent on the degree of gastric distintion. Rugal
folds are more tortuous in the nondistendJd stomach and becoire
more uniform and parallel to the gastric curvature with increasing
distention.s't2Rugal folds are smallir and more spiral in the pvlorii
antrum.2oRugal folds may not be visible if the siomach is overdis-
tended.r3Rugal folds are smaller and fewer in number in cats than
in dogs.'zAreference-range for normal rugal fold thicknessin dogs
weighing 2 to 50 kg has been reported to be 1 to g mm.2s
Gastricperistalsisand gastricemptying may be observeddirectly
,
clunng fluoroscopy with the use of positive-contrast medium. Ul_
trasound examination can also be used to assessmotility. Although
a peristaltic contraction may be seen on a conventional radiografh
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-
senceof medications that affect gastric emptying are all factors that
must be considered and standardized. If these factors can be ex-
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
at the pylorus. Emotional stress and noise may inhibit gastric
movement.2eAnxiety, fear, rage, or pain induced by physical ma-
nipulation of the patient, gastric intubation, and physical restraint
may contribute to delayed gastric emptying. Thus, patients with
delayed gastric emptying must be allowed to calm down in a quiet
environment before diagnostic significance is placed on delayed
gastric emptying. Also for these reasons, minimal significance is
usually placed on slight or minor delays in gastric emptying if
the stomach proceeds to empty in a normal manner after an
initial delay.
Studies using barium-food mixtures have been performed in an
attempt to further evaluate gastric function.l5'16 Emptying times
for individual dogs were repeatable;however, the range of normal
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-
ing times for dogs and cats varied from 4 hours for high-moisture
food to 16 hours for dry food.s An alternative technique for
evaluating gastric emptying of solids in dogs and cats has been
developed using barium-impregnated, polyethylene radiopaque
spheres (BIPS)* mixed with food.20-23The number and size of
radiopaque spheres,type and amount of food, and fasting period
must follow a standardizedprotocol. An advantageof the technique
is that it can be performed in most veterinary practices; however,
study times may be long (up to 10 hours). Some controversy
exists about the usefulnessof BIPS for gastric emptying analysis.
Scintigraphic evaluation of gastric emptying of food may be con-
sidered the "gold standard" technique. The study can be completed
in 4 to 5 hours, but availability is limited to teachins hospitals and
large institutiolls.e' 30,rl
*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
Figure 47-6. Dorsoventralgastrogram.Rugalfolds at the peripheryot the
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
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
en f ace ,
I
I Ultrasonographic examination
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
ri the need for contrast studies in many patients as gastric motility'
wall thickness and architecture, and to a lesser extent, luminal
contents may be evaluated. In addition, ultrasound examination is
less expensiveand quicker to perform than an upper GI series,and
may be equally sensitive and specific for detection of gastric dis-
ease.32Gas and ingesta within the stomach may obscure the far
wall and thus limit evaluation of the entire organ, but the lumen
Figure 47-7. Gastricdisplacementdue to hepatomegaly.A, Lateralview The
pylorus and body are displacedcaudally.B, Ventrodorsalvlew The pylorus and
ca u d a llya n d to th e le ft. F in a d
b o d ya r e d i s p l a c ed chroni cpassi vehepati c
l ia g n o sis:
congestlondue to heartwormdlsease.
and far wall can be evaluated in those patients in which the
stomach contains fluid and little gas (Fig. a7-SA). Ideally, scanning
should be performed after a l2-hour fast, and prior to barium
contrast studies. If needed, intraluminal gas can be removed via an
orogastric tube and the stomach distended with fluid.31 'n The
stomach should be scanned in longitudinal and transverseplanes.
For evaluating stomach wall layers, 7.5- to 10-mHZ transducers
are preferred, but 5-mHZ transducers may be needed to evaluate
deeper portions of the stomach. Ultrasound has been used to aid
in the diagnosis of gastric neoplasms,3sa2inflammation or infec-
tion,a3 ulcers,aaforeign bodies,at'as pyloric hypertrophy,a6gastric
mineralization,aTgastroduodenaland gastrogastricand intussuscep-
tions,a8'aeand to evaluategastropexysites.so, sl
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
may have a "wagon wheel" appearancedue to infolding of rugal
folds (see Fig. a7-88). This is especiallynoticeable in the cat. With
increasing distention, rugal folds become less prominent. Stomach
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
wall thickness averaged2.0 mm for the fundus and 2.7 mm for the
layers corresponding to the mucosal surface, mucosa, submucosa,
muscularispropria, and subserosa/serosa can be identified.33
Iayers have alternating hyperechoic and hypoechoic layers with
These
mucosal surface, submucosa, and subserosa/serosabeing hypere-
choic and the mucosa and muscularis layers hlpoechoic (see Fig.
47-8). The mean number of peristalticcontractionsobservedultra-
sonographically in dogs has been reported to be 4 to 5 contractions
per minute.33
 The Stomach 621

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.

I Abnormal radiographic and are often of value to confirm_cranial

I uttrasonographic findings becauseapatient with a.small-rirr"r
displacement of the stomach
mayilso be emaciatedor have
abdominal effusion, making tn.
Displacement ,tor#.il^ a"i6.,rf, ,o see. Cranial
displacement of the stomaJh .,i,iit, .uptur.
.il;;; or ti,.
The position of the stomach may be a useful diaphragm and herniation. of -"y rh'. il;"";;;;
indicator for recogni_ of'th. liu"., o, th.
tion or localization of some extragastricabnormalities stomach.Thus, even ttr3yh tt. .tornu.t'_uy"not
in the cranial pus, through a
abdomen. Some diseasesof the liver, ,pf..", -p."*.as, diaphragmatichernia, the position
or tn. ,t#*h is an important
and dia_ co^nsideration,in.patients.suspected
phragm may affect the stomach. rh. of having ; Jiupl,rug*atic her_
r"lutioisiip between the nra. A cranial shift of the ixis
stomach and a particular extragastric abnormality of the stofiach may help define
may help define whether the liver has he-rniated.*"i;ld"rh'.'""gh
the primary. organ involved or"the nature the diaphragm.
of it.-iri_ury t.rlorr. However, a normal axis of the stomach
The cranial surface of,the stomach i, i; in ..rch-instancesmay still
.i;; apposition with
the caudal surface of the iiver..Thus, changes excludethe possibilityof t.r"iution of pu,rt
i" ,ir. o, position of il"J,,."?TP,"r"ty oi
the.liver may causea changein position
Jf tn. .io_u.t. General_ Abdominal massesthat.originate
ized,hepatomegaly often p-d.r.., caudal .. caudal to the stomach do not
anJ ao.sul displa.ement displace the stomach craniallyibelau;;;,h.
of the stomach.saThis diiplacement U. uffi_etrical p;..nce of the liver.
if it is Instead, such masses
caused_by a mass lesion.l However,-uy U..u"r. ii_r. cardia of the ,h. ;h"d;it# stomach as they
is relatively fixed in position, .lr.n g.rr.rulir.d press agalnst and indent-the_
-"I *li"l,
stomach, or they may displaceth!
:lomacl t to the righ^tor left. The ."tutionrhip-of'an
aly produces a nonuniform displacement oithe "puto_.g- abdominal mass
stomach. Thus, on :1"_?*l
to the stomach is often of value in helping
the, lateral view. generalizedhepatomega/ ienne-wtretter the mass
.n.r' p-auces caudal originatesin the liver, spreen,or pancreas
ano corsal dtsplacementof the pylorus and (Fig. a7_I0).
body of the stomach.
This displacemenrchangesthe axis or trr. .i"-"lh
so that the axis
rs noronger parailelwith the ribs (seeFig.
a7_7A). On the ventro_ Gastric foreign bodies
dorsal or dorsoventral view, generaliz.d h'.puto-.galy
often causes Radiopaque material within the stomach
displacement of the body anj pylorus .f-,-f* is easily visualized and is
,,"_i.f, caudaliy and commonly present on survey radiographs.-ifr...,"p*i,*,
toward the left from normal (see Fig. ql_Zn). are most
iirs displacement often the. re-sultof ingested'bo.ne
changes the axis of the stomach so" that f;lil;;;.a"rii l"r. p..r.r,. u, un
,h" ;1. is no longer incidental findine with no .fi"i.uf'rlg"ii.lrrJ..-'rr,ror"
transverse. clinically
Because there is a minimal number of significant foreigi bodies, such ur
objective radiographic nrrrrrlor.r ln-J ,reeate., are also
readily visualizei and presenr no
size.displacement of thestomach
uia,irr rE oirri_ aiugrro.ti;p;;il.;. Occasionally,
i,lfT 3:]'::
uon or nepatomegaly.Gastric displacement
the stomach muy .orrLin nondescript
radiopaque material that is
becomesespeciallyiral_
uable when the liver is not visible, p., .", sgnificance. cl"r. ;,r;;;i;;;il
U.."rr.. of emaciation :j_n:;-',t:".Pte
lmportant. Another important factor clinical signs is
or abdominal effusion. In such patients, ul, is persistenceof the abnor_
*itfri" the stomach patient.is
may often be used to define the axis of i:*,Lll,h. it"ui.,"r"n""i,;i;;"ph";'"de 1 to 3 days
th. stomu.h. A small later may providevaluable
v.olumq of barium may also be given to information tni. +Z_f f .
.orrfir- ifre axis of the A greater problem exists with radiograihic
stomach. aiagrro.is of non_
opaque gastric foreign bodies. such
diaphragm is intact, cranial displacement of obji.t. ur. uru?ly arn.rrtt to
,If.the the stomach seeon survey radiographs. Gastric
.?1,,tu:.,o the.draphragm can occur only with endoscopic examination is valu_
a decreasein the size a,bleand,should be peiformed if
or rne [ver. lhrs dlsplacement results from the i;i;;;;;avaitable. Con_
cranial displacement of trast studiesmay be necessaryfor
the pylorus and body of the stomach (pig. diagnosis. S.*.uf ,ofotions exist
SZ_r. Contrast studies to aid in radiographic identihcation
;i;;;";;;;sastric foreign
 AN IM AL S
G,2 2 A B DO M E N- C OMP AN IO N

Figure 47-9. Gastricdisplacementdue to a small liver.The pylorusand body

are displacedcraniallvon lateral(A) and ventrodorsal/8/ views. Finaldiagnosis:
oortosvstemrcshunt,

: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.

Figure47-11. Persistent gastric
foreignbody.Thisradiopaque plasticmate_
rialwasalsopresenton radiographs made3 dayspreviously;
ii waseventually
removed by gastroscopy.
b-odies.The simplest technique is to use different patient positions.
If the foreign body does not shift dependently with gasiric fluid,
then a different view may help to outline the foreign body with
gas. This approach is most valuable if the foreign body remains in
the pyloric portion of the stomach and can be outlined with gas
in a Ieft recumbent lateral view (Fig. a7-12). Giving a small amount
of balum or performing a double-contrast gastrogram may make
such foreign bodies easierto visualize than does a standard gastro-
gram using a large volume of barium because a laree voh;me of
barium may completely obscure the foreign body anJ thus lead to
a false-negativeresuit. Knowledge of patient positioning is again
important becau,segas within the stomach during a contiast study
may simulate a filling defect comparable with that associatedwitL
a foreign body.
The appearanceof a foreign body on a gastrogram varies, de-
p"_"qi"g on the t)?e of foreign body present. An object such as a
solid ball createsa round, discrete filling defect within the barium
$ig. a7-13). If the object has a nonabsorbentsurface,it mav not
be visible after the stomach has emptied. Converseiy,a rag or sock
may not createan initial filling defect becausethe contrast medium
may permeate the object. Becauseof absorption and retention of
contrast medium, however, the foreign body may be better visual-
ized after the stomachhas emptied.
Gastric foreign bodies may be identified ultrasonographically.tr,rs
--
The ability to detect these objects depends on the prisence ofother
gastric contents (e.g., gas, fluid, and food), the position of the
object relative to the sound beam, and the objeit composition.
Strong acoustic shadows with or without an echogenic acoustic
interface are strongly suggestiveof foreign bodies. A semicircular
border is suggestiveof a ball. Intraluminal fluid surrounding for-
eign objects facilitates their detection and the ability to distinguish
rounded reflective foreign body surfaces from intraluminaf gas;
therefore, adding water to the stomach may be beneficial in some
patients. Objects that transmit sound may be visualized more
completely than those producing strong acoustic shadows.
The Stomach 623
Acute gastric dilation and volvulus
Acute gastric dilation and gastric vohrrlus produce gaseousdisten_
tion of the stomach. Although both fluid and gas are present in
the stomach, gaseousdistention is the predominant abnormality in
theseconditions.
Acute gaseousdistention of the stomach may be due to a com_
-
plex variety of causes.Gaseousdistention of the stomach may also
be.caused by.aerophagiathat is secondaryto severedyspneaor
pain. In such instances,the gastric distention is usually lesi severe,
and other correlative findings may be present to aid in differential
diagnosis. With.acute gastric dilation, ihe stomach is enlarged and
is filled primarily with gas but retains its normal positi-on and
anatomic- relationships. Thus, the pylorus is still loiated on the
right and the fundus on the left.- The normal position of the
stomach can.usually be determined on survey radiographs by using
and comparing the right recumbent and ieft recumbent'latera'i
views or the ventrodorsal and dorsoventral views. Recognition of
the pylorus of a distended stomach is usually easier on lateral
views than on the ventrodorsal or dorsovential view. Contrast
gastrography may help in this localization but is usually not neces_
sary.
Gastric volvulus is also associatedwith acute gaseousdistention
of the stomach. Gastric volvulus is differentiatei fro- acute sas_
eous dilation by the presenceof stomach rotation. Different diiec_
tions and
{egrees of rotation of the stomach may be present at the
time of.radiography, and the radiographic appeaianceof the stom_
ach varies, depending on the typelni degiee of rotation and the
amount of distention.sl s6As the stomach dilates, the greater curva_
ture rotates (clockwise when viewed from caudal to iranial) to lie
along the ventral abdominal wall. The pylorus continues to shift
dorsally, cranially, and to the left, and iire body of the stomach
shifts toward the right.r6 Becauseof the gastrosplenicligament, the
spleen follows the greater curvature toward the rieht.
radiographic feature of gastric voi/ulus is gas and
^ Jl_re..majo1
flurcl clrstentronof the stoma€h (more gas than fluid). Additionally,
th1. plrlorus is usually displaced aorslatty and to the left. Thus,
radiographic determination of the location of the pylorus is the key
differentiating feature between dilation and volvuius. Radiographic
Iocalization of the-pylorus is best accomplishedby making iet'ana
right recumbent lateral views or ventiodorsal and dorioventral
views. Lateral views are usually of most value. When filled with
gas, the pyloric portion of the stomach appears more tubular and
narrower than the rest of the stomach. Aithough the stomach is
filled primarily with gas, it usually contains enJugh fluid so that
the pyloric portion may fill with fluid and thus no-t be seen. Both
lateral views may be needed to be sure that the pylorus fills with
gas and can thus be recognized.
With the pylorus shifted to the left and with the patient in left
recumbency, fluid in the stomach fills the pylorus urrd gu, fills the
rest of the stomach. With the patient in right recumben"cy,gas fills
the pyloric portion and fluid shifts to the- fundus or bodv of the
stomach. Thus, the radiographic finding that the pyloric portion
fills with fluid on the left recumbent latJral view urrd nrc gu,
on the right recumbent lateral view indicates that the pylorus-ith is"on
the left side and that the stomach has rotated (Fig.47_14; see also
Fig. a7-B). Recognition of this shift is usually moie difficult on the
ventrodorsal and dorsoventral views because specific recognition
of the pyloric portion may be more difficult. positive_contrast
gastrography may be performed but is usually not needed. An
additional variarion is a voh.ulus of 360 degiees, in which the
pylorus and fundus are on their normal sidJs (Fig. 47_15) and.
diagnosis is dependent on findings at physical examination or sur_
gery.
Gastric volr..ulus may also be present without severe gastric
,.
distention. This situation may often exist for days or weeki after
grgyigus gastric decompression5T or may be present at the time of
initial presentation.2TThe aforementioned radiographic principles
 624 A B DO M E N -C OMP AN IO N
AN IM AL S

.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.

Figwe 47-13. Gastricforeign body {ball)that creates a

round,i ntral umi nal
fi l l i ngdefecton the gastro gram.
 The Stomach 625

:rlli1,6,j1rl,.;lr:tr

Figure 47-14. Gastricvolvulus.A, Left recumbent lateral

view. The stomachis greatlydistendedwith gas in the fundus
and th e b o d y .F l u i df i l l s th e p ylo r icp o r tio n ,wh ich is n o t we ll
v is ua l i z e d8., R i g h tr e c u m b e n la t te r avie
l w.T h e flu idsh iftsin r o
t he fu n d i c p o r t i o n ,a n d g a s o u tlin e sth e p ylo r icp o r tio n( P) .
Thes ec h a n g e si n d i c a t et h a t th e p ylo r u sis o n th e le ft a n d th e
f und u si s o n t h e r i g h t a n d th a t th e r e is a g a str icvo lvu lu s,In
t his p a r t i c u l apr a t i e n i t. h e p ylo r u sis d ir e cte dca u d a lr y.

Figure 47-15. Gastricvolvulus,right recumbentlateralview.

The pylorus (P) is directedcranioventrally {comparewith Fig.
47-148). The soft-tissue mass in the ventral abdomen just
caudalto the stomachi s the spl een,w hi ch i s di s pl ac edas a
resul tof the gastri cmal posi ti oni ng.
The spl eni ce nl argement
is
suggestiveof splenic vein compressionor obstruction,and
spl eni ctorsi onshoul dbe constoereo.
 626 A B DO M E N -C OMP AN IO N
A N IMA L S
still apply as a means to recognize rotation of the stomach (Figs.
47-16 and, 47-17).
Compartmentalization is a term that refers to the radiographic
appearanceof soft-tissue bands that project into or acrossthe gas-
filled lumen of the rotated stomach. These soft-tissue bands result
from folding of the stomach on itself as the folded wall projects
into the lumen and is outlined by gas within the lumen.'? These
bands may become more obvious with greater degreesof disten-
tion. With progressivedistention of the stomach, the stomach wall
becomes thinner. Gas within the gastric wall has also been de-
scribed but is infrequent.'z
As the stomach enlarges, other mobile structures within the
abdomen are displaced caudally. With severegastric distention, it
is often difficult to visualize other abdominal organs owing to
crowding. The spleen is also usually involved in gastric volvulus
and may shift with the stomach. The spleen is usually enlarged
owing to impaired circulation, but its location may vary. The
greater the gastric distention, the less likely the spleen is to be
visualized radiographically becauseof crowding of abdominal vis-
cera. Thus, splenomegaly and splenic displacement may be more
easily visualized with less severe gastric volvulus. Other changes
that may be seenwith volvulus include reflex paralytic ileus of the
small intestine, esophagealdilation, and microcardia and pulmo-
nary hypovolemia (small vessels)associatedwith shock.
tl l
Ghronic pyloric obstruction
Obstruction of gastric emptying at the pylorus may be acute or
chronic. Causes of acute obstruction include sastric volvulus as
well_as foreign bodies. Chronic pyloric obstruciion is usually the
result of narrowing of the pyloric orifice secondary to diseases
affecting the wall or blocking the orifice, such as hypertrophic
pyloric stenosis,pylorospasm, inflammation or fibrosis, neoplisia,
and mucosal antral hypertrophy. These conditions usually ciuse a
chronic, partial obstruction at the pylorus, leading to chronic
retention of gastric content.
Chronic, partial obstruction of the pylorus is often manifest on
survey radiographs as fluid-filled gastric distention, as opposed to
the acute gaseousdistention of gastric vohrrlus (Fig. 47-18). The
stomach may be quite large with chronic partial obstruction of the
pylorus. However, the enlarged stomach may be more difficult to
identifr on survey radiographs when it is filled with fluid than
when it is filled with gas. Even when distended with fluid, the
stomach still contains some gas. In these instances,however, the
gas does not totally outline or fill the entire stomach. Instead, the
smaller amount of gas floats as a bubble on top of the fluid
and should not be mistaken as the limits of the stomach (see
Fig. a7-188).
The major effect of pyloric obstructive diseasesis to restrict
Figure 47-16- Left recumbent/A/ and right recumbent/Bi
lateralviews of a dog with acutegastricdilatation.On the basis
of these radi ographificndi ngs,the pyl orusand t he fundusare
on normalsi desof the abdomen.The esophag us w as di l ated,
however, and a gastric tube could not be passed into the
stomach.Fi naldi agnosi s:360-degreegastri cv ol v ul us .N ote:
The circularopacity in the cranioventralaspect of r,B/is an
ECGelectrode.
 The Stomach G,27

Figure 47-17. Left recumbent lateral view of a dog a

f e w d a y sa f t e rg a s t r i cde co m p r e ssio n . str icvo lvu lu sis;till
Ga
pr e s e n tb u t w i t h o u te xtr e m ed ila tio n .

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,

Figure 47-18, Laleral(A)andventrodorsal1Blradiographs of two dogs with fluid_

filled gastricdistentioncausedby chronicpyioricobstiuction.The stom]achis
more
d i f f i c u l t o i d e ntifywh e n fille dwith flu id in ste a do f g a s.The l ongarrow si n,4 and
I
indicatethe caudal margin of the stomach.The smaller gastri; gas pocket
/short
arrows in 8/ should not be mistakenfor limits of the stomich. Th6 dog shown in-A
a l s oh a d h e p a to m e g a a lyn d ch o le lr th ia sts.

i*=:
 6 28 A N IMA L S
A B DO M E N -C OMP AN IO N

diagnostically adequate and that specific differentiation of the un-

derlying causemay not be possible on radiographs.

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

Figure47-21. Ventrodorsal radiograph
of the pylorus of a dogwithobstruc- measurements
of thepylorus.
tivedisease Thereis a hemisphericfillingdefectat thepylorus
thatprojects
intothelumen. Therewaspronounced
{samedogas thatin Fig.47-19). Thefillingdefectwasdueto mucosa
was hypertrophiedin a symmetricbandaround the pylorus. Finaldiagnosis: ness in a contracted, empty stomach as the stomach
chronicplasmocyticgastritis,
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
greater than 6 to 7 mm have been proposed as
deiayin gastric emptying being pathologic.3s Although gastricwall thickeningis an important
that aDnormalhnding, one must be cautiouswhen assessinq wall thick_
riall is thick_

ation of the stomach with endoscopicand biopsy studies or by

surgical exploration.
Gastric ulcers may be detected on ultrasound examination.aa
Features include the presence of a wall defect (crater) usually
within the center of a locally thickened area of stomach wall. Thb
thickened area may have loss of the normal layered appearance.
Gastric fluid accumulation and decreased motility may also be
noted. Ulcers due to non-neoplastic causesdo not appear distinctly
different from those seenwith neoplasms.

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

Figure 47-24. Longitudinalultrasonograms ot gas-

A , Lymphosarcoma
tri c neopl asi a. i n the s tomac hw al l
of a cat. The stomachwall (betweencursorslis thick-
ened (1.23cm), hvpoechoi c, and has l os t the normal
layeredappearance. The normalwall layersare seen
i n the unaffectedcaudalw al l . B , Adenoc arc i noma in
the stomacl"wall of a dog. Tne wall (betweencursors)
i s uni forml ythi ckenedi 0.97 cm) and dec reas edi n
echogenicity.The normal layeredappearanceis dis-
rupted.Caudalis to the r/grhland ventralis to the top.
 The Stomach 631
.$,rrr"

Figure 47-25. Lateralsurvey radrographot

the abdomen
ol a g o Sw i t h . a t h i c k g a str ;cwa lt.tn "- r u ,i"t."n e J
*.ti;;";i
v rsu a i l z eIdn t h e v e n t r a lm td a b d o .n eann d is
a sso c,a tewilh d
a na r r o w t. u b u l a tg a s { i l le dlu m e n .Ru g a fo
l ld swe r e e n la r g e d
on.a g a s t r o g r a mF. r n adial g n o sr s: ch r o n ich yp e r tr o p h ic
g a itr i

a false-positivediagnosisof gastnc masscan

:n.d th".l:-pty.and Acute gastritis may result,from, a
ilq the stomachwirh water may help distinguish variety of causesand is rarely
i:.::^T.:-- "rrtenf false_positive
Derweentrue-.and associatedwith radiographic abnormaliiies.
lesions,but real_timJobserv-ation Chronlc gastritis is
oI gastrlcmotllity may be an easierway to distinguish icaly.anJ ;;t ;i;; i*r, r,o
_ avariety
two as a lack of motility is usually seen in
betweenthe :?t':"1::ur"9:Tl::ed-din
ur causes.bxamples include diseases
# abnormal wall such as chronic *ropt ii
gastritis, chronic hvoertrop_hic^
g_astritis,.".i""ifrU.
or histopathologic evaluation is necessaryfor a gastritis, and
l1g_T:1,: $1gloSl9
oennruv^e pythiosis and zvqorivcolis."
dlagnosis.specimens can be obtained via ultrasound_ ffi"r"fas, large rugal
;'"1"".,tf'"f
folds, nodules, oi a thicrened
guloed nne-needleaspirationor tissuecore bioDsv.tt,tt gastric wall may be seenwith these
7-zs\.n ultrasJnographi; fi;i';; or gastricpyth-
Diffuse diseases of the stomach *::""':: Jtf I
:ltt:,,uno lygomlcosis are similarto thosereiortej fo. guJtri.
The,stomach may be involved diffuseiy in a variety neoplasms.a3,TsNonfungai inflammation _uy .urr'r. diffuse
of diseasesthat stomach
produce inflammation, hypertrophy,'atrophl, wallthickening with m"ainten""..oi*urilffi 1;:,,
tJ mineralization.
Soft-tissuecalcification may occur
in associationwith chronic
s2,83In such
renal failure.aT, patients,_i".r"iir.ti"" of the gastric
wall may be visible radiographicait;
; ;hi;;li;ear,
opacities(Fig. a7-26). Rygul mineralization'ir-on.n mineralized
"
visuaiized when the stomach"is.-p,y
u"Jif,. mineralzed -"rt;;;ilt
mucosal
fold pattern is more tiehtty groupJJ:
;i;;;;phic findings of
dogs.with uremic gast-ropatiy include
tfrr.f..".?"grrtric wall and
anda hy-perechoi.
;o".;11h. _"."."i_r"_inat
inrerface
::g1tj:ldr
owlng to mucosal mineralization.aT,
8r Ultrasound
was thought to
be more sensitive than radiography f"r;;;;;;;*"f
gastric lesions
associatedwith uremia.aT

References
l. Evans HE: Millert Anatomy of
the Dog, 3rd ed. philadelphia, W_B
Saunders, 1993.
2. O'Brien TR: RadiosraphicDiagnosis
ofAbdominal Disordersin the Dog and
Philadelphia,WB Saun-dero, Cat.
1978.
UJ"*n.t WR, Bartels JE: Co-ntrast
radiography ofthe digestive tract: Indications,
"-r,
techniques, and complications. Vet Clin fV-if, ,ir1
;j;;,;;;:"
Interpretation of abdominal survey
,4.,Root-CR: radiographs. Vet Clin North Am
4:763, 1974.

J: castric emptying time in the dog and cat.

,Z.,rl,tiln;;.t J Am Anim Hosp Assoc

6. Gomez JA: The gastrointesrinal

contrast study: Methods and interpretation.
Clin North Am 4:805: 1974. Vet

Bargai,U: The effect ofxylazine

hydrochloride on the radiographic appearance
-,7; stomach and intestine in the dog.
the of
Vet Radiol ZZ:AO,tggl.'""'"
8. Hogan PM, Aronson E: Effect of-sedation
on transit time offeline gastrointestinal
contrast studies. Vet Radiol 29:g5, 1994.

9. Steln PF, Twedt D, Toombs W The

effectofintrayenous diazepam on solid phase
gastric emptying in normal cats. Vet
Radiol Ufi."r"r"J'j"e;or,"ir,rr.
10. Scrivani PV Bednarski W,
y:fl.Cy Effects of acepromazine and butorphanol
upper gastrointestinal tra* examinaiion
Ctose-upvenrrodorsat in dogs. Am J vet Res
l!?^"^i:1r 39,, surveyradiograph
of a dogwith ;;rry;:t[;;*""st
cnrontcrenalfailure.
Thin,cur
rusar
rords
ortr,estomacr,'a#Ji?:!Jil:':h:f":f;;n'* thatpararrer
the ll. MiyabayashJ T, Morqan ip: lJpper
gastrointestinal examinations; A radiographic
study of clinicarlynorma'i Beaglepuppies.
J smalr Anim pract 32:83, r99r.
 6 32 AN IM AL S
A B DO M EN -C OMP AN IO N
12. Evans SM, Lauffer I: Double-contrast gastrography in the normal dog. Vet Radiol
22:2, 1981.
13. Evans SM, Biery DN: Double-contrast gastrography in the cat: Technique and
normal radiographic appearance.Vet Radiol 24:3' 1983'
14. Root CR, Morgan JP: Contrast radiography of the upper gastrointestinal tract in
the dog. I Small Anim Pract 10:279, 1969.
15. Burns I. Fox SM: The use of a barium meal to evaluate total gastric emptying
time in the dog. Vet Radiol 27:169,1986.
16. Miybayashi T, Morgan IP: Gastric emptying in the normal dog: A contrast
radiograph technique. Vet Radiol 25:187, 1984.
17. Allan GS, Rendano VI, Quick CB, et al: Gastrografin as a gastrointestinal contrast
medium in the cat. Vet Radiol 20:i10, 1979.
18. Agut A, SanchezvalverdeMA, Torrecillas FE, et al: Iohexol as a gastrointestinal
contrast medium in the cat. Vet Radiol Ultrasound 35:164' 1994.
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.
20. Allan FL Guilford WG, Robertson ID, Jones BR: Gastric emptying of solid
radiopaque markers in healthy dogs. Vet Radiol Ultrasound 37:336' 1996.
21. Guilford GW, Lawoko CRO, Allan FI: Accuracy oflocalizing radiopaque markers
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.
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,
1997.
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
dilatation-volvulus.Am J Vet Res53:1961,1992.
24. Grandage ): The radiologic apPearance of stomach gas in the dog. Aust Vet J
50:529,1974.
25. Jakovljevic S, Gibbs C: Radiographic assessmentof gastric mucosal fold thickness
in dogs. Am J Vet Res 54:1827,1993.
ti 26. Twedt DC, Wingfield WE: Diseasesof the stomach. ln Ettinger SJ (ed): Textbook
of Veterinary Internal Medicine, vol 2, 2nd ed. Philadelphia, WB Saunders, 1983,
p 1233.
27. Funkquist B, Garmer L: Pathogenetic and therapeutic aspects of torsion of the
canine stomach. I Small Anim Pract 8:523, 1967'
28. Gibbs C, Pearson H: The radiological diagnosis of gastrointestinal obstruction in
the dog. I Small Anim Pract 14:61, 1973.
29. Gue M, Fioramonti J, Frexinos J, et al: Influence of acoustic stress by noise on
gastrointestinalmotility in dogs. Dig Dis Sci 32:l4ll, 1987.
30. Hornof Wl, Koblik PD, Strombeck DR, et al: Scintigraphic evaluation of solid-
phase gastric emptying in the dog. Vet Radiol 30:242' 1989.
31. Kunze CR Hoskinson JL Butine MD, et al: Evaluation of solid phase radiolabels
of dog food for gastric emptying. Vet Radiol Ultrasound 40:169, 1999.
32. Keith DG, Wortman JA, Saunders HM, et al: A comparison of the sensitivity and
specificity of barium gastrography and ultrasonography for gastric and duodenal
disease [abstract]. Vet Radiol Ultrasound 40:657' 1999.
33. Penninck DG, Nyland TG, Fisher PE, et al: Ultrasonography ofthe normal canine
gastrointestinal tract. Vet Radiol 30:272, 1989.
34. Lamb CR: Abdominal ultrasonography in small animals: Intestinal tract and
mesentery, kidneys, adrenal glands, uterus, and prostate. J Small Anim Prc'r 3It295'
1990.
35. Penninck DG: Characteristicsof gastrointestinal tumors. Vet Clin North Am Small
Anim Pract 28:777, 1998.
36. Penninck DG, Moore AS, Tidwell AS, et al: Ultrasonography of alimentary lymph-
osarcoma in the cat. Vet Radiol Ultrasound 35:299, 1994.
37. Penninck DG, Moore AS, Gliatto J: Ultrasonography of canine gastric epithelial
neoplasia. Vet Radiol Ultrasound 39i342, 1998.
38. Kaser-Hotz B, Hauser B, Arnold P: Ultrasonographic findings in canine gastric
neoplasia in 13 patients. Vet Radiol Ultrasound 37:51, 1996.
39. Grooters AM, Biller DS, Ward H, et al: Ultrasonographic appearance of feline
alimentary llmphoma. Vet Radiol Ultrasound 35:468, 1994.
40. Rivers BJ, Walter PA, Johnston GR, et al: Canine gastric neoplasia: Utility of
ultrasonography in diagnosis. J Am Anim Hosp Assoc 33:144' 1997.
41. Penninck DG, Nyland TG, Kerr LY, et al: Ultrasonographic evaluation of gastroin-
testinal diseasesin small animals. Vet Radiol Ultrasound 3l:134, 1990.
42. Lamb CR; Ultrasonographic appearance of primary gastric neoplasia in 21 dogs'
I Small Anim Pract 40.211, 1999'
43. Graham JR Newell SM, Roberts GD, et al: Ultrasonographic features of canine
gastrointestinal plthiosis. Vet Radiol Ultrasound 4l:273, 2000.
44. Penninck DG, Matz M, Tidwell AS: Ultrasonography of gastric ulceration in the
dog. Vet Radiol Ultrasound 38:308,1997.
45. Tidwell AS, Penninck DG; Ultrasonography of gastrointestinal foreign bodies. Vet
Radiol Ultrasound 33:160, 1992.
46. Biller DS, Partington BP, Miyabayashi I et al: Ultrasonographic appearance of
chronic hlpertrophic pyloric gastropathy in the dog. Vet Radiol Ultrasound 35:30,
1994.
47. Grooters AM, Miyabayashi T, Biller DS, et al: Sonographic appearance of uremic
gastropathy in four dogs. Vet Radiol Ultrasound 35:35, 1994.
48. Huml RA, Konde LJ, Sellon RK, et al: Gastrogastric intussusception in a dog. Vet
Radiol Ultrasound 33:150, 1992.
49. Watson Pl: Gastroduodenal intussusception in a young dog. J Small Anim Pract
38:163, 1997.
50. Tanno F, Weber U, Wacker CH, et al: Ultrasonographic comparison of adhesions
induced by two different methods of gastropexl in the dog. ] Small Anim Pract
39:432,1998.
51. Wacker CA, Weber UT, Tanno F, et al: Ultrasonographic evaluation of adhesions
induced by incisional gastropexy in 16 dogs. I Small Anim Pruct 39:379, 1998.
52. Agut A, Wood AKW, Martin tCA; Sonographic observations of the gastroduodenal
;unction of dogs. Am I Vet Res 57:1266,1996.
53. Goggin IM, Biller DS, Debey BM, et al: Ultrasonographic measurement of gastro-
intestinal wall thickness and the ultrasonographic appearance of the ileocolic region
in healthy cats. J Am Anim Hosp Assoc 36:224, 2000.
54. Suter PF: Radiographic diagnosis of liver diseasein dogs and cats. Vet Clin North
Am Small Anim Pract l2:I53,1982.
55. Funkquist B: Gastric torsion in the dog: I. Radiological picture during nonsurgical
treatment related to the pathological anatomy and to the future clinical course. I Small
Anim Pract 20:73,1979.
56. Kneller SK: Radiographic interpretation of the gastric dilatation-volvulus complex
in the dog. J Am Anim Hosp Assoc 12:154,1976.
57. Frendin l, Funquist B, Stavenborn M, et al; Gastric displacement in dogs without
clinical signs of acute dilatation. J Small Anim Pract 29:775, 1988.
58. Rhodes WH, Brodey RS: The differential diagnosis of pyloric obstructions in the
dog. J Am Vet Radiol Soc 6:65, 1965.
59. Zboralske FF: Gastric ulcer. In Margulis AR, Burhenne Hf (eds): Alimentary Tract
Roentgenology. St. Louis, CV Mosby, 1967.
60. Howard EB, Sawa TR, Nielson SW, et al: Mastocltoma and gastroduodenal
ulceration. Vet Pathol 6:146, 1969.
61. Robbins SL; Pathologic Basis of Disease.Philadelphia, WB Saunders, 1974.
62. fones RD, Baynes RE, Nimitz CT: Nonsteroidal anti-inflammatory drug toxicosis
in dogs and cats:240 cases(1989-1990).J Am Vet Med Assoc 201:475,1992.
63. Stanton ME, Bright RM: Gastroduodenal ulceration in dogs. J Vet Intern Med
3:238,1989.
64. Wallace MS, Zawie DA, Gawey MS, et al: Gastric ulceration in the dog secondary
to the use on nonsteroidal anti-inflammatory drugs. J Am Anim Hosp Assoc 26:467,
1990.
65. Nelson SW: The discovery of gastric ulcers and the differential diagnosis between
benignancy and malignancy. Radiol Clin North Am 7:5,1969.
66. Porcher P, Buffard P: Malignancy of the stomach. In Margulis AR, Burhenne HI
(eds): Alimentary Tract Roentgenology. St. Louis, CV Mosby, 1967.
67. Hayden DW Nelson SW: Canine alimentary neoplasia. Zentralbl Veterinarmed
l Al 20:1, 1973.
68. Sautter JH, Hanlon GF: Gastric neoplasms in the dog: A report of 20 cases.J Am
Vet Med Assoc 166:691,1975.
69. Barber DL: Radiographic aspects of gastric ulcers in dogs: A comParative review
and report of 5 casehistories. Vet Radiol 23:109, 1982.
70. Willard MD: Diseasesof the stomach. In Ettinger SJ,Feldman EC (eds): Textbook
of Veterinary Internal Medicine, vol 2, 4th ed. Philadelphia, WB Saunders, 1995,
p 1143.
71. Murray M, Robinson PB, McKeating FJ, et al: Primary gastric neoplasia in the
dog: A clinico-pathological study. Yet Rec 91i474, 1972.
72. Patnaik AK, Huryitz AI, Johnson GE: Canine gastric adenocarcinoma. Vet Pathol
15:600,1978.
73. Brodey RS: Alimentary tract neoplasms in the cat: A clincopathologic survey o{
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

Vomiting, diarrhea,weight loss,abdominal pain,

and paipation of Survey radiographsof a mature dog
a midabdominal mass are the most cominon or cat that has a moderate
cliniial'.ig.r. oi amount of intraperitone_al
intestinal diseasein small animals. Abdominal fat shouldprovide good definition of
,uaiog.uph",_uy the intestinal serosalsurfaces(Fig.
assistthe clinician a a definitive diagnosisor may provide a8_1') Anillls younger thun 6
information that is helpful
-:\". in decision makiig b.t*..r, of age or those who u'r.
medical or T9"ih., tur,. poo, ,..osul
surgical treatment, but radiographs should "not definition owing to lack of intra-abJominijut.,
"-u.iut"J
take precedence s.rorur surfaces
over a complete history, a thorough physicai should be r-ooih and are most easily
examinition, and seenin regionswhere there
minimf superimposition of loopsl wh;;-;;_.rous
tests. Survey iadiographs, ultrason"ri"Of,, l1 toops are
ljltfl.,t:Tratory
ano tntestrnal contrast examinations may be summated, particularly in the centralabdomen,
useful aids'in'the th. s"ror"l surfaces
diagnosisof both acute and chronic inteJtinal ot normal intestinesmay be indistinct.
Jirord".r. The pa_ This ,houia .,ot be misinter_
preted as being indicarive of abdomin"l
to symptomatic
therapyfor vomiting ;ii;;". Another mis_
:,:1illit^9i.,r.l11ta
l:,,,l.rpo"d
uegivena moreexrensive J=9ilg impresslon of reduced ,..o.ui a.nrri,io]-, lccurs when there
:jrii:iii1 work_up, inctudinf is little or no gas in rhe small intestinai
andsonographic studies.
Thefollowinginformatioi il_;;.'"
lt1i"Cr.iplr.
rs provtdeclas a guide to inlerpretationof radiographic Belluse.of the great_variationi" .urri.r.
Uoay size and in the
and sono_ magnification effectsof radiographic
graphic changesthat occur in the small intestin?l i_"ginf.-u'rp.cific measure_
tract. Although ment for normal diameter of the small
radiographic and sonographic abnormalities UJ*.i i, difficult to estab_
are not present in lish. Severalschemesfor relativeb"*.iair"r.i.,
every intestinal disorder, one or more of the roentgen huu. b..n reported
signs and *. ne.arbybonesas the_referenc.
sonographicpatternsdiscussedin the following ll,1l 48_2). Three
sectionscharacter_ schemesof maximal normal diameter"r".rr*r'irig.
rze many lesions. 1."rorr_to)r..osa) measure_
hT been reported for the dog:
-...n1 of a ribu; (2) not-exceeding if l elce"airrg twice the
width ""i
tf,. fr.rgfri"itfre
I The normal small bowel b:dy of g.d (:) a ratiJ tfr.-L"r]rn.I
central part of
small intestinal
:_l: .rz];
drameterto the heieht of the body "i
of L5 at it, ,r"r.o*.rt point that
Radiography is less than 1.6.,'B"ecause cats tend to be similar in body size, a
The standard views used to evaluate the small more specificcriterion can be made
for them. ihe diarneterof the
bowel are the normal feline small bowel should
lateral and ventrodorsalviews. The right_ .*.;;;-ii ;m,7 or rwice the
::.111b,.-:l l:f,-to-right "and height of the central portion of the "ot L4
t3t5rat vrew using the standard vertical x_ray u..,.U."i'Uoay.s Aithough
lo l..tt beam, t..stightly *d;;
n_or^lzontal x-ray beam views that make use of the gravitational jll:..i,'?*l'- ,h;;;;num and iteum
-uy
'ruuru nave apprormately the same luminal diameter.eAttempts
enr":ul be usedas needed.Comp..rs,on radiogra_ to judge the thicknessof the intestinrL;;li-;;:;;rey
plly can alsoTd
^?1|:lflt1 be usefulin displacingoverlappingintestinalshadows radiographs
are, unreliable. It is important that
from, a specific region of interestj Spe.ih. ifdications u nor_ui .n pty Uo_"T f6op
for these wrth a small volume of intraluminal
supplemental views are discussedin later sections. air not be mistaken for a
For elective pathologicallythickenedsegment.
abdominal radiographsof patientswith chronic True thickening of the intestinal
ciinicai signs,it is judged by ultrasound, by
most desirable prepare the patient by withholdin ::,1"::^ItJ.. a cont?aststudy, or by
.to g foold for Z+ palpatton.'0
nours and admtntsteringa cleansingenema2 to
4 hours beforethe The small bowel should.beuniformly
radlographrcexamination. This preparation produces distributed
-"p throughout the
the desired cavity, occupying.space
empty intestinal tract. However, for the patient f:f":i] ,uf.." by distensible
with acute abdomi- organs (stomachor urinary bladder),"or
nal pain, acute onset of persistent,rornitirrg,o. putpuUle, solid organs (lirr.a
enlarged kidneys), or fat. In the dog, ,f,. ..""i"i-a.ilELruf'ff.*ur" ,pt..rr, o.
fluid- or gas-filled bowel ioops, no specific is fixed
ii.pu*tlo., rs necessary. along the caudal surface 6f th.
In fact, ,tghi ,id.;i;" liver by the
.in..thesepatients, ihe patiern oi gu. fluid can be hepatoduodenalligament. The desclndi"j
diagnostically very helpful and may be disturlbed",.a a""a."r_ lies along
bf u, .r._u. The the right abdominal wall. The .",rdnl
roentgen sign assessment for the smali intestine is summarizedin drro'd.Jli""ur. is iocated
at midabdomen, with the ascending
Margination,.size,position, ,h"p., *J radiopacity d";;;;; iontinuing from
IIO]: ]|t; can this point.directly crania_lto th. ."""JJ-;;;;i"n
assess:drn. su1v.eyradiographs,but mucosal irregularities ,r-'. stomach.
:: and Distal to this poinr, the toops .f j.j";;;
aDnormal pe'starsis or transit time must ;;;';; "r u,ry position
be determined from not occupied by other organs. In
contrast studiesor ultrasound. ihe cat, th'e lranial duodenar
a sharper angte with tt. pyio.,,, than in
:::rTjr11l]f :.:11., the

Table 48-1. Roentgen signs in the small intestine

iffj?*::::ffftll*,:il,*,iiil:1
,1""?'#ilii'.".::'J"iff
men' As in the dog, the ascending
duodenum .orr.... in a craniai
direction until it reaches,fr" ,,.fr*fl
Margination-serosalsurfacedefinition lir.l";"# f".p. are rhen
located throughout the rest of the
Size -dia m et er of lum en mesogastr ic area.Common
Position-Locationwithin abdominalcaviry positional variations of small_bowel
,."" i"'"o._"i aog. and cats
Shape-contour of bowel looos include (1) a full stomach.di.plu.i;;
il;-U"*.j-i""a"r\y; (2) a
Radiopacity-lumen contentsand bowel wall arybladder.
displacing
ifr. t;;"i ;;;ailp (3 _
Architecture-mucosa/bowelwa ll smoothness liT:*,:1,.1.'1
aDoomlnat tat deposition in obesecats,causing ) intra
the small bowel to
Motility-contrast medium transit time be located ..trt.ully and on the right
side; (4) in very obesecats,
fat displacing the bowel into the
J.".*iiil.'if ihe abdominal

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
portion of the pendulous abdominal cavity' Positional changesin
ihe small intestine may also be indicative of disease in adjacent
organs,as is noted in ChaPter39.
ihe nor*al small bowel is recognized in survey radiographs as
smooth, continuously curving tubes, or as solid circles or rings
(see Fig. 48-1). These shap-s are produced by the contractile
activity*of the smooth muscle. Segmentalcontractions give-rise
to spherical shapes,whereas peristaltic contractions cause long
tubular shapes.
The radiopacity of the normal small intestine is variable because
of differing opu.iti.t of material within the lumen' In a nonfasted
animal, any oi the following may be seenin the lumen: air; ingesta
of a grainy or mottled which may include mineral or
"ppeutun.",
metai opacity; or fluid that is of homogeneous soft-tissue opacity'
The nondiscietionaryeating habits of some dogs and cats result in
mineral/metallic opacities of smail size in the small intestinal lu-
men. Clay-based cat litter and small gravel -from dog runs are
commonly seen.Gastrointestinal medications that contain calcium'
magnesium, aluminum, bismuth, qr silicate can impart significant
radlopacityto the intestinal content.rrSome pet vitamin and min-
eral supplements contain sufficient mineral to be visible' In general'
tablets or capsulescontaining minerals, either as active ingredients
or in the coating process,utJ likely to be visible than liquids
-or.a fasted animal, the lumen may
containing thesi minerals.tt In
contain a small amount of ingested air, or it may be of homoge-
@0@o@o@o
B
Figure 48-1. Serosaledges of small intestineare easllyseen
al B ow el s eg-
i n thi s dog, w hi ch has abundanti ntraperi tonefat
ments seen end-onappearas ri ngsi f the l ume n c ontal nsal r or
as roundnodul esi f the l umeni s empty or conta i nsfl ui d.
neous fluid or soft-tissue opacity. In the fasted cat' gas is rareiy
present in the small intestine, but in fasted dogs, 30oloto 60% of the
small bowel content may be gas.'''2Animals stressedby handling or
with dyspnea frequently are more aerophagic and have increased
numbers of intestinal loops filled with air. The bowel wall should
be of a uniform soft-tissue opacity. This uniformity is most easily
assessed in loops that contain air.
Positive-contrast examination (barium'
iodinated agents, and impregnated spheres)
Indications
Contrast media added to the small bowel can be used in many
instances to increase the yield of diagnostic information. Agents
that increase the opacity of the intestinal tract are used most
frequently and include liquid barium products, organic iodinated
liquids, and more recently,barium-impregnatedmarkers' The in-
foimation gained from any contrast study is often limited as a
result of poor patient selection,poor patient preparation,or inap-
propriate technique. The complete barium or organic iodine con-
irasi radiographic evaluation of the stomach and small bowel is
time consuming for the veterinarian and can be expensivefor the
animal's owner. Becauseof the potential for a low yield of diagnos-
tic information from this procedure, a contrast study should be
reserved for the patient in which a diagnosis or approach to
treatment cannot be made from the combined clinical information
Figure 48-2. Schemesfor relativenormalsmall intestlnal
di tmeter i n the dog and cat. A , The dl am eterof the s mal l
Lntestine;8, the height of the centralportionof the body of
L2, C , the w i dth of a ri b.N ormal l yA shoul dbe l es sthan B or
2 ti mes c.
 The SmallBowel G,41
and survey radiographs.In many patients, ultrasound
evaluation elecriveupper gastrointestinal tract examination,
rs capabre of providing diagnostic information l"l 1n. a 24_hour
about the small rasr ls recommendedbefore contrast
bowei; this information often negates the need medium administration. An
for a contrast slguja be-given 2 to 4 hours before
radiographic study. 111y the contrasr study to
attow emptying of residual fluid and
The clinical signs that most frequently warrant air.
an intestinal Becausemost sedativedrugs.affect gastrointestinal
contrast study include the following: motility, their
use should be avoided. Geneial u".rtfi.ti.,
u"Jtranquilizers, such
persistentvomiting with negativefindings on as promazine hydrochloride, fentanyl
,'1^.O.u,. survey or droperidol,'".d #;;;
ntmsi hydrochloride, Lave been shown to
slow the passageof barium
2. Recurrent vomiting,. especialiyin those animals through the intestine.,1,22
refractory to When ..dJ;; ;i;'." is necessary,a
therapy and without other organ diseaseto ."Oi"i; combination
:IT-p-l:T:lI
tne vomltlng; 5,,1Ti.ldlir.pam 12.z mgir<!lietuminehydrochlo_
0nmg/kgdiazepam.in
separatesyiing.r,grvenintramus_
3. Paipableabdominal masswithout obstructive i::. i"d-9
cutarly 20 minutes before administration
bowel signs on of barium) has been
survey radiographs; shown to have minimal effect on
4. Acute abdominal pain with an unusualor unexplained (0.05 mg/
abnor- kg) int^ravenousacetylpromazine has -;iili;;^;_dose
b.".r'r"com-.nded
-;;tan for seda_
maiity seenin the survey radiographs; tion of fractious doss.,, Medicati"",
th;i anticholinergic
5. Weight loss with intermitteni or recurrent diar.rhea.e,
r3_r6 drugs should also b"e discontinued
at least 24 hours (preferablv
6. Melena;and 4.8-72 hours) before the contrast study.r3
Th" i"fil;; ;;;#;1
7. Hematemesis. the motility of the intestinuti.u.t;;odd
:::T be kept in mind
Gastrointestinaltract contrast studies are frequently when ""one is evaluating both survey
not infor_ and contrast raiiographic
studies. A recent reviera
mative in patients that have chronic diarrhea
However, information that
without .,ro_iting.
be gained from a contrast study in
or,ou,ro,,f
r,u,;;;;tJ;':',j:nf
;:n:T*::,il,-,*iffi
,ft:
-can
these patients includes the followin"g: consideredrelative to the interpreiatlon
oi dlr*re_ versus drug_
induced radiographic.changes.,,'Amonjti.*
mole thorough evaluationof mucosalabnormalities; to affect the
]. 1t
2. Length of intestine.affected(focal, regional,
3. Thicknessof bowel wall:
or generalized); i;fi['-::Tiil,ii'Jl'f
ili;.lT,Hf ji:
:::'f.",nJlX;1*X.i
""t.a

r.J:i.l hours. opioid peptides (such as

4. Abnormalitiesin peristalticactivity and intestinal I:rft"]T,r*"g
lur butorpha-
transit time; can nave erther a stimulatory or
5. Improved determination of luminal size; an inhibitory effect, on
motility,^dependingon the animal ,p".i",
6. A more completeevaluationof luminal contents; 9ljlll-l:r,ii"l
regron of gut affected.Severaldrugs, tt.
and such as cisapride,are "nJnow
7. Determination of patencyof the lumen. commonly used for their gastropiokinetic
effects. Although the
ma.;orsite of action of thesedrugi is
Contraindications the stomach,cisapridehas a
stimulatory effect in both the du"odenum
Contrast evaluation is not warranted in the patient ;;; ;h. jejunum. Thus,
with survey when assessment is attempted using ."rii"rir,ray,
radiographic evidenceof obstructiveileus and these drugs
a palpableabdomi'_ may mask a small intesrinil motiliti "
nal mass.raMinimal additional information i, to disorder puit.rr,.,,
f. gainedbecause Standard views are routinely.usei_. obh;;;;j;*.
contrast.medjum passesonly slowly through to project the
the atonic bowel pyloric sphincter or a particular
proximal to the obstruction, especialiyin thJ uU'or_'uiity _ay be added as
weakenedor debili_ Right-to-left lateral and a"r.*.ritr"i
tated animal. If the clinical radiografhic findings are 1..:d.d.1'j 'zo
rnformation
views may add
to the evaluation of the duodenum it
"r,d.,r.,ru.y
strongly suggestiveof mechanical "surge.y eurlyfilming.
obstruction, is indicated. B1]um sulfatesuspensionis the .or,,.uri
Further attemptsto define.thespecificsite and _.Jl.rm of choice in
tyf. of obstructinj most instances.Micropuiverizedpreparations
lesion with contrast media. only delay and p6irifrfy are availabl. i";l;;
complicatE powder form (Barosperse,. Lafayeitebfr"r-..ri..fs,
surgery and causeadditional patient siress.Tire Lafayette,IN)
use of iodlnated ,rliq"ia suspension rtiquid Buro.p".r", iufayettepharmaceu_
agents.and barium-impregnatedmarkers would T
urdrs;r\ovapaque,prckerInternational,
also not be indi- -9i Cleveland,OH; E_Z_paque,
cateclln such patients. Inc., Westbury. Ny). The
Patientswith obvious surveyradiographicfindings l.1uq barium sulfate
offree perito- suspensronare summarizedin Thble"Ar"".a.rif
neai gas,that is, gas that is not resijuaj fro- ."cht 4}-2.t3.io.zo.zz-z,t
If perforation
celiotomy or of the intestinal tract is suspected,use of
due to abdominocentesis,are also ,ro, upprof.lute barium sulf,ateis not
patients for (seeprevious section,.,Conrraindications,,).
contrast intestinal studies.In.these patients, the ::._:TTlld"d
ganrc.lodrne An or_
peritoneal gas is preparation designed for the gastrointestinal
most likely due to gastrointestinalpe;foration. If perforation should be used when perforation ,, tract
Jfthe ,,rorrgty'.;pected (Gastro_
intestinaltracl is suspected, use of barium sulfaters not recom_ grafin, meglumine diatrizoate oral
mended becausethe combination of barium and ingesta solutioi,' *-alco Diagnostics,
within the Princeton, NI; Oral Hypaque, sodium
peritoneai cavity may cau,semore severeperitonitii, diatrizoateiiq,rid, Ny.o_"d,
foreign body Princeton, Nl). Occasionilly, a small
granuiomas,or serosaladhesions.r{r' ,, Attempting t"", l, _irr.a becausethe
to ideitify the ranidlyty tn. ..,o.u. ir;;;i.
location_ofthe perforation is not as i-portuni'u, :?*:-t:::llorbed stiil suspected
sivemedicaland surgicalintervention. fioviding aggres_ study has beencompleted,barium may demoistrare
:i:.,::-t:otn"
rus reaK more obuously (see Fig.
The particular properties of water_solubleorganic 4g_lS). Becauseof the rapid
iodine con_ preparations ttirough tf,. guri-t"t"rtinal
trast media result in either ionic or nonionic p"reparatrons. lfj::C^. ^1f.]:dine tract,
Most be used to quickty determine the patency
of the ionic types are hypertonic and cause ,n irrflu* ;l:":,,T:1,r fg i,.:
tne rumen. l-he potentiaily hazardous oi
of fluid into adverse effects from the
rne gasrrontestmaltract. In the young and debilitated, hyperosmolarity of the iodine contrast
especially
dehydrated patient, this can *o.r.rl ui,y hypovolemic media, howerner,should
state; thus, alwaysbe kept in mind. Nonionic, **.t-roirrfi'ioar.rut.a
theseare contraindicated.ro contrast
(omnipaque,
su"on_wi;;;p pharmaceu_
ilfl\:::y',i"f:T:l
York' NY)' which
Technique :'-tott' ltY are of low osmolality,havebeen used
Ior gastrointestinal contrast studies in urri_u1r.rill These agents
An empty gastrointestinal tract is preferred if optimal
information causeless fluid movement into the
is to be obtained from the contrait study. For patients bowel iumen but are relatively
with acute costly. Becausethey are transparent,
severeabdominal distress,however, no preparation the iodinated agents aliow
is usualiy possi_ endoscopicevaluation to be perform"d
the patient with an acute abdominat crisii may irn_ediut.llifollowing
lt:,^i19lyllly,.
suiler addrttonai rnjury from administration of laxatives the imaging study. the ua"u",ut.. u"a
or enemas. l!fltetion,o1 disadvantage!
ot water-solublecontrast media are
summaiized in Table 4g_2.
 642 A B DO N/ I E N -C O MP AN IOAN
N IMA L S

Tahle 48-2. Intestinal contrast agents

Contrast agent Disadvantages Uses
B arium su lfatesuspens ions Very radiopaque M a y i n d u c eg r a n u l o m a so r Routinegastrointestinaltract
Ex c ellentm uc os ald e t a i l a d h e s i o n si f l e a k e di n t o contraststudies
Rem ainin s us pens i o n peritonealcavity
Resistdilution
iner t
Phy s iologic ally
Low cost
B ariu m sulfa te,USP Inexpensive I n a d e q u a t em u c o s a ld e t a i l Not recommended
Tendsto precipitate
Orga nicio din e (ion ic ) Rapidt r ans itt im e May form precipitates Suspectedintestinal
Nonirritatingto serosal May be absorbedacross perforation
solu tion s
surfaces mucosa and excretedby
Rapidlyresorbedfollowing urinary tract
ex t r alum inalleaka g e Hypertonicitycauses:
F l u i df l u x i n t o l u m e n
Dilution of contrast
Electrolyteimbalance
Dehydration
Org an iciod ine (no nionic ) Rapidt r ans itt im e Expensive Suspectedperforation
solu tion s Nonirritating Pre-endoscopy
Resorbedfollowing Young or debilitatedPatienl
ex t r alum inalleaka g e
Low osmolality
Does not become
progressivelYdilute
Radiopaquemarkers- Eas eof adm inis t r a t i o n N o m u c o s a li n f o r m a t i o n Assessorocolictransit rate
Bariu m impre gn at ed Not liquid Assesspresenceof absence
sp he res(BIPS) Orogastrictubing not needed of obstructivedisease
Can be given with food
.

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

F i g u r e 4 8 - 3 . N or m a lca n in eb a r iu m u p p e r g a str o in te sti nal

t r a c t s t u d y 3 0 m i n ute s a fte r co n tr a stm e d iu m a d m in istr ati on.
N o t e t h e e x c e l l e n rt a d io o a citv
o f th e co n tr a stm e d iu ma n d the
s h a r pd e f i n i t i o no f t h e m u co sasu
l r fa ce .

ffi,.ryni|rl."

Figure 484. Normalcanineiodine-preparation uppergastron-

test naltractstudy30 mi nutesaftercontrastm edi umadmi ni s tra-
ti on. Whereascontrastmedi um opacrtyi s g ood n the bow ei
l ocatedi n the caudalabdomen,the contrastmedi umrs drl uted
(decreased opaci tyand poor def ni t on of muc os a)i n the c rani al
abdomenbecauseof fl ui denteri ngthe bow e i n res pons eto the
hyperosmol ar natureof the contrastmed um.

Table 484. Upper gastrointestinal tract film sequence

lonic and nonionic Structures usually opacified
Barium organic iodine in normal animals*
Dog lm m ediat e lmmediate Stomach
15 m inut es S t o m a c h ,d u o d e n u m
30 m inut es 15 minutes S t o m a c h ,d u o d e n u m ,j e j u n u m
t hour S t o m a c h ,d u o d e n u m ,j e j u n u m
2 hour s 30 minutes Stomach,all parts of small bowel
4 hour s t hour S m a l l b o w e l ,c o l o n
I m m ediat e lmmediate Stomach
5 m inut es 5 minutes S t o m a c h ,d u o d e n u m
30 m inut es 30 minutes All parts of small bowel
t hour t hour Small bowel,colon
*Owing to the extreme variability of individual transit times, this list is only an approximation
of the parts of the gastrointestinal tract seen at these times.

:#
 AN IM AL S
6 ,44 A B DO M E N -C O MP AN IO N

echoic mucosal layer is the thickest of the individual layers, and

thus is visually dominant.35When fluid is within the lumen, the
mucosal surface is normally hyperechoic. If gas is present within
the lumen, a prominent reverberation artifact occurs in a relatively
long length of bowel, and a hyperechoic ring-down artifact is
presentduring peristalticcontraction.The normal duodenum can
usually be distinctly identified by its superficialright-side location;
it can be traced cranially into the stomach and caudally to the
descendingloop, which coursestoward the left. The jejunum and
most of the ileum are seenas nondescriptloops. The terminal l-
to 2-cm portion of the ileum, or the ileocolicjunction, has recentiy
been describedin the cat as appearinglike a "wagon-whee1"owing
to projection of the mucosainto the lumen.3' The normal number
of contractionsis 4 to 5 per minute for the proximal duodenum,
and I to 3 per minute for the remainder of the small intestine.'n
Normal mesenteric lymph nodes are unlikely to be imaged with
the use of 5- to 7.5-MHz transducers.However, when l0-MHz
transducersare used, these lymph nodes can be found in the
relaxed patient.3aNormal lymph nodes are typically isoechoicto
the associated fat and may not be readily apparent, even when
high-frequency transducers are used. However, the location of the
jejunal nodestoshould be assessedin any patient suspectedof
having small intestinaldisease.As additional reviewsare published,
patterns of change are emerging that suggest specific intestinal
diseasesin animals.

I The abnormal small bowel

Dilating bowel disease
Figure 48-5. Normalcaninebariumupper gastrointestinal tract study wlth
ps e u d o u l c e rasl o n gt h e a n tim e se n te r suic r fa ceo f th e d e sce n di ngduodenum. Numerous diseaseprocessesresult in abnormal dilation of the
Th e s ei n d e n t a t t o nasr e n o r m a lva r ia tlo n in o f the duodenum
s th e a p p e a r a n ce small intestine. Failure of intestinal contents to pass through the
of y o u n gd o g sa n da r ed u eto d e p r e ssioin n th e m u co saa t site sof l ymphoi dfol - tract is called ileus. Ileus may be mechanical, caused by physical
llcl e s .

meal. The type of meal influences the rate of gastric emptying;

thus, strict adherence to the manufacturer's recommendations must
be maintained when the product is used for calculation of gastric
emptying times and assessment of orocolic transit.

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.

Figu r e 4 8 - 7 , N o r m alca n in eb a r iu m u p p e r g a str o in te stin al
t rac t s t u d y i n w h i c h a f r n e lyfim b r ia te dm u co sa su
l r fa cem a y o e
s ee n .T h i s a p p e a r a n cof e th e in te r fa ceb e twe e nth e b a r iu ma n d
t he m u c o s ai s s e e n i n s om e n o r m a a l n im a ls.
obstruction of the bowel lumen, or functionai (paralysis),in which
casethe peristalticcontractionsof the bowel ceaseowinq to vascu-
lar or neuromuscularabnormalitieswithin the bowel wall. In func-
tional ileus, the bowel lumen remains patent. Table 4B-5 lists
considerationsfor the more common pnit.rrl, of bowel dilation.
Patternsof dilation include the following: (i ) focal/mild-one to
three loops are involved,and luminal distentionsare 1.5 to 2 times
normal; (2) focal/severe-one to three loops are involved, and
luminal distention is greaterthan 2 times normal (Fig. a8*10); (3)
generalized/mild-all loops are involved,and luminal distention is
1.5 to 2 times normal (Fig. B-1 1); and (4) generalized/severe-all
Pww
Figure 48-8. Norma segmentalintestrnalcontractionsdunng a can ne up-
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
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
c onlr a s tm e d t u m .
The SmallBowel 645
loops are involved, and luminal distention is qreaterthan 2 times
normal.
Mechanical obstruction
The small intestinallumen can be occludedby largeforeign objects;
by intussusception;by proliferating tissuemasses"fromthe wail of
the bowel; or by extrinsiclesionsthat compressthe bowel. Mechan_
ical obstruction can be complete or partial. The most consistent
radiographicsign of mechanicalobstruction is variabledilation of
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
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
normal bowel should raise the index of suspicion for a
iartial
obstruction. Nonmineralized, nonmetallic foreign objects are much
more difficult to identif' than mineralized or metallic objects. Fruit
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

Figure 48-1O. Mechanicalileus,causedby a radiopaque foreign

object {rock).Note the focal, extensiveair-distendedsmall bowel
l oops(approxi matel2.5
y ti mes normaldi ameter).

F i g u r e 4 8 - 1 1 . M ild , g e n e r a lize d e n la r g e m e not f sm a ll bow el
l u m e n( a p p r o x i m a tefolyu r tim e sth e wid th o f th e a d ja ce nrtib).Thi s
d o g h a d a r e c e n t l yr u p tu r e dsp le n ich e m a n g io sa r co m{ nao t vi si bl e
o n t h i s i m a g e )l e a din gto a b d o m in apl a in a n d su b se q u e ntfunc-
ti o n a li l e u s .
their geometrically shaped radiolucencies on survey radiographs
(Fig. 48-13).38The nonopaque foreign object with irregular zur-
faces, especially with grooves, can entrap small, minerilized in-
gested debris and gas, and may become more visible. Careful
application of abdominal compression may enhance the visibility
of these foreign objects. Based on clinical signs, the use of 24-
hour serial survey radiographs,a contrast study, or an ultrasound
evaluation may be necessaryto confirm the diagnosis of partial
obstruction suggested by abnormal luminal contenis.Ifobstruction
is complete, the barium may take a long time to reach the level of
the obstruction owing to marked reduction in intestinal motility.
Dilated loops typically have a smooth barium-mucosa interface.le
However, at the region of obstruction, the shape of the barium
should outline the foreign object, with the object itself creatins a
filling defect in the barium column. Figure 48-14 schematica"lly
depicts variations in the contrast-intraluminal object interface.
Fenestratedforeign objects that causeonly partial obstruction allow
barium to pass around or through them. If only a small volume of
barium passesthrough or around such an object, the volume may
be insufficient to achieve physiologic distention of the remainder
of the bowel. In Figure 48-15, barium accumulation can be seen
in dilated bowel orad to a baby bottle nipple, as well as a thin
stream of barium in the bowel distal to the partial obstruction.
Figure 48-12. Mechanicalileus in a dog with an ileocotrc
rr t u s s u s c e p t i o n
A.l t h ou g hin tu ssu sce p tioca n n n o tb e d ia g n o s ed
f ro m t h i s i m a g e t, h e r a d io g r a p hficn d in g sa r e str o n g lysu g g e sti ve
of m e c h a n i c aol b s t r u ctio n .Air - d iste n d e dsta cke dlo o p s lo p en
arrows) and small particlesof radiopaqueingesta (solidarrow) are
trapped proximalto the obstruction,The latter findinq is com_
m o n l y s e e n i n i n s t a n ce so f ch r o n jco r slo wly d e ve lo p in gp a r trat
ob s t r u c t i o n .
I:.
The SmallBowel 647
This reduced contrast volume may lead to a false impression of
narrowed bowel diameter distal to the obstruction.
The. ultrasonographic appearanceof ingested foreign material is
variable, according to the composition of the materiaFo The acous_
tic pattern causedby the rigid foreign object may have a shape that
can be specificallyrecognized.Objeits that transmit the beam, that
rs, some types of rubber balls, are more readily identified. Those
that createa strong reflection with marked acoustic shadowing may
be more difficult to define initially. When these objects "cause
incomplete obstruction, they are frequently associated with in_
creased intestinal motility resulting from irritation. With more
complete obstruction, the foreign lU;..t .nuv l. associatedwith
accumulation of fluid in the associatedbowel.
Linear.foreignmaterial (e.g.,string, nylon hosiery) that becomes
trapped in the intestine usually causes'both an abnormal shape
and contour of the loops and an abnormal luminal content D;t_
tern.' Typically, some portion of the linear material becomes fixed
at an orad location-in the stomach most commonly in dogs, and
under the tongue most commonly in cats.arThe remaindeiof the
length passesinto the small intesiine. The peristaltic action of the
bowel causesit to "climb" up the linear foreign body, which results
in a pleated, or plicated, appearanceof the-affected loops. These
loops may not become particularly distended, but gas commonly
 648 A B DO M E N -C O MP AN IO N
AN IN /A L S
IL
' ei gn bodi es.V et R adi olU l trasound35:87,1994,)
ll. becomestrapped in pocketsformed by the pleats.The result is an
abnormal pattern of round, tapered,and short tubular connected
gas shapes (Fig. a8-16). If the linear material is absorptive in
nature, like fabric, it can absorb fluid incompletely and show a
mottled-to-linear, streaked gas pattern. A serious complication of
chronic linear foreign body is laceration of the intestinal wall. If
the laceration is small, serosaladhesion to an adjacent loop can
occur, resulting in a fixed position of two or more loops. If the
lacerationis large,septicperitonitis and potential gasleakageoccur.
A comparative study between dogs and cats noted several signifi-
cant differences:Dogs tended to be older; dogs showedlessirregu-
larity in the gas pattern; one quarter of dogs had concurrent
intussusception;on both radiographic and surgical assessment,
dogs revealed greater evidence of bowel trauma-bowel laceration
Figurc 48-14. Shapesof contrastinterfacewith an intraluminalobject.The
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
(stippling)topass.With completeobstruction,there is no bariumin the bowel
distal to it and thereforeno definitionof the caudalsurfaceof the object.A,
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,
8, Flat,straightforeignobject,such as hard leather,and wood splinter.
C Fruitpit or nut. D, Retrogradeintussusception (invagination of bowel in the pathic causes.aa
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 ) .
Figure 48-73. Variousnonopaqueforeignbodiesra-
di ographedi n a w ater bath. 7, S ec ti on of c ornc ob
viewed side-on;2, section of corncobviewed end-on;
3, peach pit; 4, walnuts; 5 acorns; 6, chestnuts; Z
w i ne cork; 8, avocadopi t. {FromLam b C R , H ans onK :
R adi ol ogi cal
i denti fi cati onof nonopa quei ntes ti nalfor-
and peritonitis; and the probability of death as a result of linear
foreign body in dogs was nearly double that in cats.ara3
Barium contrast studies improve detection of the abnormal
shapeand contour of the loops iontaining the linear foreign mate-
rial (Fig. 48-17). Thin linear material such as string or cord may
not be particularly visible as a filling defect. However, if the fixed
component of the string is in a wad, this should be seenas a filling
defect in the barium, for example, in the pyloric region of the
stomach. It is cautioned, however, that such a mass of string in the
stomach may not be seen in the initial views when a large volume
of barium masks the material. However, in later images, when the
barium should have exited the stomach, a barium-soaked or coated
mass remains in the stomach, indicating the retained foreign mate-
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
wall or obliteration ofthe wall layer pattern has not been described.
Intussusception, the invagination of one portion (intussuscep-
tum) of the gastrointestinal tract into the lumen (intussuscipiens)
of an adjacent segment,can be initiated by many events,including
motility disorders, inflammatory wall lesions, neoplasia, or idio-
Although intussusceptions can occur anywhere
along the digestive tract, the majority occur in the small intestinal
 The SmallBowel 649

*- )

"ai

rl
l

;i

Figure 48-15. Mechanicalobstructionof the jejunum by a

foreignobject (babybottle nipple[arrows]).

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

Figure 48-16. Noncontinuousgas typicalof plicated,zig_ ; -1

zag,accordion-like contourof the small intestjne(arrows)in-a
cat with a linear intestinalforeign oblect. A string was re_
moved at surgery.
650 A B DO M E N -C O MP AN IO N
AN IN 1 A L S

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

struction. Most present clinically during the phase of partial ob-

struction, with focal mild to severedistention. Additional features
of thesernassesare discussedin the later section,"Infiltrative dis-
eases."
Lesions originating outside the intestinal wall can cause com-
pressionon a loop and result in partial or complete obstruction.
Lesions in this category include adhesions from prior surgery,
abdominal boundary hernias (Fig. a8-21), and occasionally, masses
originating from other abdominal organs.

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.

Figure tI8-2O, Transverseplane ultrasoundimage showing a con-
centric ring pattern with an eccentricovoid hyperechoicregion,The
centralring (longarrow)representsthe intussusceptum,The eccentric
hyperechoicmalerial(shortarrows)is most likelyintussusceptedmes-
e n t e r i cf a t .
Barium contrast study should show distended loops, delayed
transit, and normal to nonspecific changes in the barium texture
and mucosal border. There are no barium contrast findings spe-
cifically diagnostic of the diseasescausing functional ileus. Floc-
culation of the barium, a cobblestoneappearanceof the barium-
mucosa interface, and an irregular undulation of the mucosal
border can be seenthroughout the progressionofparvovirus enter-
itis.aeBecausethese diseasesmimic complete mechanical obstruc-
tion, the role ofthe barium contrast study is to exclude mechanical
obstruction.
No specific ultrasound featureshave been describedto differenti-
ate functional ileus from chronic comDletemechanical obstruction.
The finding of peristalsis suggestsexclusion of functional ileus. A
thorough search of the bowel should be done to look for obvious
obstructive causes, such as intussusception, intraluminal foreign
material, or extrinsic masses.
Strangulation of the intestine through a hernia, mesenteric vol-
l'ulus, and intestinal sclerosis with pseudo-obstruction are other
lesscommon diseaseswhose primary radiographic changeis dilated
F i g u r e 4 8 - 2 1 . P ote n tia llo ca tio n sfo r d isp la ce m e n to f
b o w l i n t r a u m a t i co r co n g e n itahl e r n ia tio n7. , d ia p h r a g m a tic;
2, peritoneopericardial; 3, umbilical;4, vental: 5, inguinal;6,
p e l v i cd i a p h r a g m a t ic.
The SmallBowel 651
intestinal loops. Tiaumatic tears or developmental hernias of the
peritoneal cavity boundaries can have small intestinal loops dis-
placed through them. The identification of such loops ii often
quite easy owing to gas within the lumen. The lumen can become
enlarged if the hole reduces in size to become constrictive, or if
the loop twists. Mesenteric volvulus results in occlusion of the
cranial mesenteric artery. The reduced blood supply leads to ische-
mic necrosis,gastrointestinaltoxin release,and shock.s0The initiat-
ing event for volvulus typically is not known. The majority of dogs
reported have been of larger breed size.Many presenting dogs have
no distant or immediate prior history of gastrointestinalsigns and
are presented in a shock state. However, in other dogs, mesenteric
volvulus has occurred subsequent to prior treatment for acute
gastric dilatation with volvulus and intussusception. A series of
dogs had previous clinical diagnosisof pancreaticinsufficiencyand
clinical signs of vomiting." The radiographic signs are moderate
to severedilation of the small intestine with fluid and gas. perito-
neal effusion may be concurrent. Five dogs have been reported to
havea syndromeof intestinalpseudo-obstruction,with histopatho-
 652 AN IM AL S
A B DO M E N -C O MP AN IO N
logic changesrestricted to the tunica muscularis but apparently not
involving the myenteric plexuses.52-s' Diagnosis was based on full-
thickness intestinal biopsy, and all dogs had progressivedeteriora-
tion due to emaciation from malabsorption. These dogs were con-
sidered to have histopathologic changes consistent with systemic
scleroderma, similar to those found in humans.
lnfiltrative diseases
Infiltrative diseasesof the bowel wall include idiopathic inflamma-
tory bowel disease(IBD), infectious inflammation, and neoplasia.
Any of these diseasescan have focal or diffuse involvement of the
small intestine. Survey radiographic changes caused by these dis-
easesare nonspecific and frequently minimal. IBD most commonly
causes no radiographic abnormalities. Infectious and neoplastic
infiltration may lead to signs of dilation, an abnormal gas pattern
with or without dilation (Fig. a8-22), and an abnormal mucosal
margin with a narrowed lumen. Neoplasia may become large
enough to cause a mass effect. Metastasis to the regional lymph
node may be large enough to create a mass effect despite a small
size of the primary tumor in the intestinal wall. These diseases
causecellular infiltration within the layers of the bowel wall; there-
fore, the most anticipated change is that of bowel wall thickness
and uniformity. Bowel wall thickness cannot be reliably determined
from survey radiographs but can be evaluated in barium contrast
I and ultrasound studies. Survey radiographic findings that should
heighten the suspicion of infiltrative small bowel disease in a
I patient with appropriate clinical signs include increasedsmall
bowel gasin cats;increasedgas-to-fluidratio in cats;and decreased
I gas-to-fluid ratio in dogs.''
Inflammatory bowel disease refers broadly to gastrointestinal
I
tract diseasesfor which a specificetiologic causecannot be found,
J
and in which the intestinal wall is infiltrated by inflammatory
cells.ssThere are no radiographic features specific to the spectrum
of this group of inflammatory changes. Survey radiographs are
usuallywithin normal limits. BecauseIBD is in part a diagnosisby
exclusion, the negative radiographic findings aid in the exclusion
of other diseases.
Infectious enteritis includes those diseasescaused by viruses
or bacterial, rickettsial, and fungal organisms. Parvovirus (canine
parvovirus-2)-induced radiographic changeshave been discussed
in a previous section with reference to a differential diagnosis for
abnormal bowel dilation. An enzyme-linked immunosorbent assay
(ELISA) test for canine parvovirus-2 in the fecesshould be done
before barium contrast or ultrasound is used, when there is reason-
able suspicion of this viral enteritis. Other viral diseasesthat infect
the small intestinal tract have not been shown to causeany specific
radiographic or sonographicchanges,and thus are not discussed
here. Bacterial overgrowth in the small intestine has also not been
related to specific radiographic or sonographic changes.Bacterial
abscessescan occur as focal lesions associatedwith the intestinal
wall. These could be a consequenceof partial or complete intestinal
perforation by foreign material, with subsequent adhesions and
abscessformation. A mottled appearance can be seen in such
abscesses when gas from the lumen replacesexudate draining into
the lumen. Abscessescan also be associatedwith the small intestine
but may be extrinsic to the wall. This may occur postoperatively
when surgical spongeshave not been removed, or may be second-
ary to a pancreatic abscess.Inflammation of the proximal duode-
num secondary to pancreatitis can causethe duodinum to take on
a fixed or rigid appearance demonstrated by mild dilation with
gas.s6A left lateral view may aid in showing this mild dilation.
Although not common, reported mycotic infections of the intesti-
nal tract include histoplasmosis,cryptococcosis,s'and pythiosis.
Pythiosis, an opportunistic water-borne fungus, has recently been
diagnosedin dogs in Oklahoma (including the northern region),
in addition to its more common endemic localein the statesalong
the Gulf Coast.s8' sePathologic changesare often quite advancedby
the time of clinical presentation. Pyogranulomatous lesions cause
localized thickening of the intestinal wall that frequently extends
through the serosa,along the mesentery, and into the mesenteric
Iymph nodes. This combination results in a palpable abdominal
mass. The ultrasound features of a series of dogs having pythiosis
included thickening of the intestinal wall associatedwith loss of
the layer pattern.60The sonographic features are very similar to
those of intestinal neoolasia. Histoloeic examination of tissue is
required for diagnosis.
Common neoplasmsof the small intestine include the malignant
tumors-adenocarcinoma, lymphosarcoma, mastocytoma, and lei-
omyosarcoma. Atypical tumors reported are extraskeletaltumors,
osteosarcoma,fibrosarcoma,carcinoid, neurilemmoma, and hem-
angiosarcoma.6r 7aBenign adenomatouspolyps of the duodenum
have also been reported in cats, with an increasedfrequency noted
among Asian breeds.Ts In survey radiographs,no signs unique to
any of these tumors are noted. They may create no changes,may
be seen as soft-tissue massesof variable size, or may cause partial
to complete obstruction, resulting in bowel dilation signs.Accumu-
lation of radiopaque foreign material may be seenas a consequence
of partial obstruction. Identification of these lesions is improved
with either positive-contrast or ultrasound evaluation.
In barium contrast studies, there may be a contrast contour
change,an irregular mucosal interface abnormality, a wall thickness
Figure 48-22. Surveyradiographin which focal dilationand an
i rregul ar,
scal l opedmucosalsurfaceof a smal lbow el s egmentare
seen. Evaluation of the lengthof intestineaffectedand the severity
of changesin the mucosarequirea bariumstudy or ultrasoundeval-
uati on.

Figure 48-23. Eccentrically narrowedbowel lumen,smooth mucosalsurface,and dilation
of bowel proximalto the narrowingcharacterize this focal intramuralobstruction(arrowheadd.
Hi s t o p a t h o l o gdi ci a g n o siswa s a d e n o ca r cin o moaf b o we l wa ll . E ccentri cnarrow i ngusual ,,
oc c u r sw i t h a m a s sl e sio na; p o st- tr a u m a tico r p o stin fla m m a tory
stri ctureusual l ycausesmore
s y m m e t f l cn a r r o w t n g .
change,or a luminal size effect as a result of any infiltrative disease
process. Unfortunately, no positive-contrast findings, either single
or in combination, have been discovered to differentiate non-
neoplastic from neoplastic infiltrative disease.t,However, the posi-
tive-contrast study may be used to corroborate a suspicion of
abnormality from the survey radiographs, and to better define the
Iocation of a lesion with respect to whether endoscopicversus
surgical biopsy would be most effective. This is especiallyvalid for
the practice that has no availability of ultrasound. Survey radio-
graphic findings that warrant positive-contrast evaluation when
infiltrative small bowel disease is strongly suspected include in-
creased small bowel gas in cats; increased gas-to-fluid ratio in
cats;and decreasedgas-to-fluidratio in dogs.I2Tissue proliferation
associatedwith intestinal wall tumors typicaliy causes smoothly
The SmallBowel 653
t"
d"
i
"l
rounded protrusions toward the lumen (Fig. 48-23). The effect is
an indentation into the barium column. When the proliferations
are muitifocal along a length of bowel, they have been likened to
thumb- or fingerprints. These indentations are differentiated from
normal or hyperperistaltic contractions in that they are symmetri-
cal {directly opposite);those from proliferativetissue,however,are
asymmetrical (Figs. 48-24 through 48-26). Ulceration of the mu-
cosa associatedwith infiltrative diseasecan be extremely difficult
to identif' when small. When larger ulceration is present, an
irregular mucosal margin is more ikely. Occasionally, ulceration
extendsvery deep into the wall layersand causesa "spiked,'pattern
$ig, a8-27). Foci of barium may remain adherentto an ulier and
may be evident after all of the other barium has passeddistally. A
frequent pattern seenwith annular infiltration by-adenocarcinoma
Figure 48-24. Barium upper gastrointestinal tract study (same
pati entas that j n Fi g.48-22).N ormalbow el i s seen i n the c rani al
abdomen(solidarrow).Abnormalmucosajarchitectureis indicated
by irregular,nonsymmetricindentationsof contrastmedium /open
arrows)and spiculated,raggedinterfacebetween the bariumand
the mucosa (curvedarrow).The affected sectionof bowel is also
moderatel ydi l ated.R adi ographidicagnosi sw as se gmentali nfi l tra-
ti ve bow el w al l di sease,such as severe enteri ti s ,neopl as i a,
or
necrosi s.H i stopathol ogidicagnosi w
s as l ymphosarc oma.
6 54 A B DO N/ E N -C OMP AN IOANN IMA L S

ffift.lll!lill
q- . . * * q l B

Figure 48-25. Hyperperistalsis is seen in this barium upper

gastroi ntesti naltract study 5 mi nutesafter contras tmedi umad-
mi ni strati on.
H ypersegmentati on causesnumerousbeadi k e ac -
cumulationsof contrast medium /so/ld arrow). Thin strands of
bariumthat extend for severalcentimeters(openarrow) can be
seen w hen transi tti me throughthe smal l bow e l i s fas terthan
normal as. i n thi s oatl ent.

is narrowing of the lumen by offset indentations in the barium.
This has been called an "apple-core" appearance.ra'66 It is not,
however,specificfor a diagnosisof neoplasia,and biopsy must be
done for diagnosis.Other diseasesthat can produce secondary
ulceration include mast cell tumors, hepatic disease,uremia, and
recurrent pancreatitis.T6-0"
When greaterlengthsof the intestineare
abnormal, lymphosarcoma,non-neoplasticinfiltrative disease,or
ischenriaand necrosisshould be suspected(Figs. 48-28 and 48-
r2, 81 8s
)q\
When evaluatedsonographically,in general,intestinal neoplasia
more typically obliterates the intestinal wall layer pattern and
more greatly thickens the wall than do other common types of
inflammatory infiltrates.There is no ultrasonographicpattern that
is entirely specific for any of the types of small intestinal neoplasia.
However, most (75%) cats with alimentary lymphosarcoma have
transmural circumferential (as is seen in the transverseplane)
thickening (4-22 mm), with the wall layers replaced by hypoechoic
tissue.Half of thesecatshaveassociatedenlargementof the mesen-
teric lymph nodes.8u, 87Intestinal adenocarcin-oma of cats tends to
causetransmural asymmetrical thickening, with the wall layer pat-
tern lost and repiacedby tissueof mixed echogenicity.r'Much less
has been describedfor the intestinal neoplasmsof the dog, with
the exceptionof smooth-muscletumors, leiomyosarcomaand leio-
myoma.8eLeiomyosarcomatends to be found as a large (2-8 cm

Figure 48-26. lrritationof duodenumand jejunum is indicatedby irregular,serratedmuco-

sal surface(whitearrows)of duodenumand hypersegmenlation (blackarrod. The midcentral
area,which is devoid of bowel loops,was causedby necrotic,hemorrhagicpancreatitisand
abscessformationthat resulted10 days after a penetratingwound.
 The SmallBowel 658

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).

thick),.eccentricallypositioned masswith mixed echogenicity.

The
larger the mass' the more likely it is that areas of irecrosis
appearas hypoechoicfoci. The largesizeof many leromyosarcomas
will

difficulty in the determinationof whether rhey are

f':.i"iilJ:,*'.u:*'111"ff.ru:';:ixli#i
antipsoriasisointment containing .ul.it.,oi
;;;tgues have noted
:ir:::
ot ::-..
bov/el origin. other tumors of the canine small intestine are :1T1? l*' of vomiting,
ultrasonographyof the
*hi.h;t
;* ;;fr
iui?og.upr,y
u.,ao.
insufliciently reported to enable any conclusionsabout abdomen.,r biff*. calcifi"caiionof the
trends in gastrointestinaltract may be found in these
their sonographic.appearance.urtrasound evaluation patienis.Radiographi-
of the intes- cally,. the degree of calcification typt.uiiy
ilne comDrnedwrth ultrasound_guidedfine_needleaspiration i;;r;;-" thin line of
and an enhancedcontiast eifect.Differentiatdiagno_
microcore biopsy is an accurate method of minimally :ft:lr1flllting
srs lor thrs type of diffuse mineralization
invasive should include o"ther
diasnosis.er) causesof hypercalceuria, including ,.u.r. p.i-u.y renal disease.
MLcellaneous small intestinal diseases Pneumatosisintestinalisand pneumatosis
coli both indicate the
presenceof air in the intestina-lriall.rs
Opacity.changesin the intestinalwall are very uncommon. Numerom u"a".fyhg .uur;,
Diffuse can lead to this qasaccumulation,i".lrdi;;;.;;oliring
mineralization of the wall can occur by metastatic .r,t.ro.oli_
calcification tis, ischemicnecrosissecondaryto volvulus,
trauma, and bacterial

Figure 48-28. Numerousradiorucent murarindentatjons,resultingin filringdefects,are seen

b*@
t e s spr o m in e n r iy
r n th e je ju n u m T
. h e sed e fe c i s.pp_ri * i r,.rri pn"ni ,,*"
]I :ndenta
i! -1ly otdi o
" nnys" , a n d ,

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
nor colonic pneumatosis has been reported in the dog or cat;
however, the author has seen a case of pneumatosis coli that
occurred after numerous enemas.
References
1 Armbrust LJ, Biller DS, Hoskinson JJ: Case examplesdenonstrating the clinical
utility of obtaining both right and left lateral abdominal radiographs in small animals.
I Am Anim Hosp Assoc36;531,2000.
2. Armbrust L), Biller DS, Hoskinson JJ:Compressionradiography:An old technique
revisited.J Am Anim Hosp Assoc36:537,2000.
3. Root CR: Interpretation of abdominal survey radiographs. Vet Clin North Am
4:763, 1974.
4. Owens JM, Biery DN: RadiographicInterpretationfor the Small Animal Clinician,
2nd ed. Baltimore, Williams & Wilkins, 1999.
5. JergensAE, Moore PM, Haynes JS, et al: Idiopathic inflammatory bowel disease
in dogs and cats: 84 cases(1987-1990).I Am Vet Med Assoc201:1603,1992.
6. Graham JR Lord PR Harrison fM: Quantitative estimation of intestinal dilation
as a predictor of obstruction in the dog. J Small Anim Pract 39:521,1998.
7. Morgan JP: The upper gastrointestinal examination in the cat: Nornal radio-
graphic appearanceusing positive-contrastmedium. Vet Radiol 22:159,1981.
8. Riedesel EA: Unpublished data. 1996.
9. O'Brien TR: Small intestine. In O'Brien TR (ed): Radiographic Diagnosis of
Abdominal Disorders in the Dog and Cat. Philadelphia, WB Saunders, 1978.
10. Penninck DG, Nyland T, Fisher B et al: Ultrasonography of normal canine
gastrointestinal tract. Vet Radiol 30:272, 1989.
11. Hall lA, Watrous BA: Effect of pharmaceuticals on radiographic appearance of
selected examinations of the abdomen and thorax. Vet Clin North Am Small Anim
Pract 30:349.2000.
12. Weichselbaum RC, FeeneyDA, Hayden DW: Comparison ofupper gastrointestinal
radiographic findings to histopathologic observations: A retrospective study of 41
dogs and cats with suspected small bowel infiltrative disease.Vet Radiol Ultrasound
35i418, 1994.
13. Brawner WR, Bartels JE: Contrast radiography of the digestive tract: Indications,
techniques and complications. Vet Clin North Am Small Anim Pract 13:599, 1983.
14. Gomez JA: The gastrointestinal contrast study. Vet Clin North Am 4:805, 1974.
15. Morgan JR Silverman S: Radiographic evaluation ofthe digestive tract. In Tech-
niques of Veterinary Radiography, 3rd ed. Davis, CA, Veterinary Radiology Associ-
ates,1982.
16. Root CR: Contrast radiography of the alimentary tract. In Ticer iW (ed): Radio-
graphic Technique in Veterinary Practice. Philadelphia, WB Saunders, 1984.
17. Foley Ml, Ghahremani GG, Rogers LF: Reappraisal of contrast media used to
detect upper gastrointestinal perforations. Radiology 144:231, 1982.
18. Ott DJ, Gelfand DW: Gastrointestinal contrast agents: Indications, uses, and risks.
IAMA 249:2380,1983.
Fi gure 48-29. General i zed asymmetri cthum bprrnti ndenta-
ti ons throughoutthe smal l bow el . Thi s patterni s unus ualbut
suggestsextensi vei nfi l trati ve
mucosaL
di sease{s uc has l y mpho-
sarcoma,parvovi ral enteri ti s,l ymphocyti c-pl as mac yenteri
ti c ti s ),
w al l soasm.or both.
19. SeltzerSE, JonesB, Mclaughlin GC: Proper choice of contrast agentsin emergency
gastrointestinal radiology. Crit Rev Diagn lmaging 12:79, 1979.
20. Allan GS, Rendano VT, Quick CB, et al: Gastrografin as a gastrointestinal contrast
nedium in the cat. Vet Radiol 20:3, 1979.
21. Hsu WH, McNeel SV: Effect of yohimbine on xylazine-induced prolongation of
gastrointestinaltransit in dogs. ) Am Vet Med Assoc 183:297,1983.
22. Zontrne WJ: Effect of chemical restraint drugs on the passageof barium sulfate
through the stomach and duodenum ofdogs. J Am Vet Med Assoc 162:878,1973.
23. Hogan PM, Aronson E: Effect of sedationon transit time of feline gastrointestinal
contrast studies.Vet Radiol 29:85, 1988.
24. Ker r LV,Kobl i k PD ; C ontr as tr adi ogr aphyInM
. or ganR ( ed) : H a n d b o o k o f S ma l l
Animal Practice.New York, Churchill Livingstone,1988.
25. Farrow CS, Green R, Shively M: Radiology of the Cat. St. Louis, Mosby-Year
Book, 1994.
26. Ticer )W: The abdomen. In Ticer JW (ed): Radiographic Technique in Veterinary
Practice.Philadelphia,WB Saunders,1984.
27. Root CR, Morgan JP; Contrast radiography of the upper gastrointestinal tract in
the dog: A conparison of micropulverized barium. I Small Anim Prcct l\i279, 1969.
28. Agut A, Sanchez-ValverdeMA, LasaosaJM, et al: Use of lohexol as a gastrointesti-
nal contrast mediun in the dog. Vet Radiol Ultrasound 34:71,1993.
29. Agut A, Sanchez-ValverdeME, Torrecillas FE, et al: Iohexol as a gastrointestinal
contrast medium in the cat. Vet Radiol Ultrasound 35:l64, 1993.
30. Williams ), Biller DS, Myer CW, et al: Use of iohexol as a gastrointestinal contrast
ag€nt in three dogs, five cats and one bild. I Am Vet Med Assoc 202:624,1993.
31. Williams l, Biller DS, Miyabayashi T, et al: Evaluation oflohexol as a gastrointesti-
nal contrast medium in normal cats.Vet Radiol Ultrasound 34:310,1993.
32. Thrall DE, Leininger jR: Irregular intestinal mucosal margination in the dog:
Normal or abnormal?I Small Anim Pract 17:305,1976.
33. Robertson ID, Burbridge HM: Pros and cons of barium impregnated polyethylene
spheresin gastrointestinal disease.Vet Clin North Arn Small Anim Pract 30:449,2000.
34. Goggin JM, Biller DS, Debey BM, et al: Ultrasonographic measurement of gastro-
intestinal wall thickress and the ultrasonographic appearance of the ileocolic region
in healthy cats.J Am Anim Hosp Assoc 36:224,2000.
35. Lamb CR: Recent developments in diagnostic imaging of the gastrointestinal tract
ofthe dog and cat. Vet Clin North Am Small Anim Pract 29:307,1999.
36. Pugh CR: Ultrasonographic examination of the abdominal lymph nodes in the
dog. Vet Radiol Ultrasound 35:110,1994.
37. Luttgen PJ, Whitney MS, Wolf AM, Scruggs DW: Heinz body hemolytic anemia
associated with high plasma zinc concentration in a dog. I Am Vet Med Assoc
1,97:1347.1990.
38. Lamb DR, Hansson K: Radiological identification on nonopaque intestinal foreign
bodies.Vet Radiol Ultrasound 3587,1994.
39. Kleine LJ: The role of radiography in the diagnosis of intestinal obstruction in
dogs and cats.Comp Contin Educ Vet Pract l:44,1979.
40. Tidwell AS, Penninck DG: Ultrasonography of gastrointestinal foreign bodies. Vet
Radiol Ultrasound 33:160,1992.
 The S mallBowel 657
41. Evans KL, Smeak DD, Biller DS: Gastrointestinal linear
foreign bodies in 32 73. Takahashi T, Kadosawa T, Nagase M,
dogs: A retrospective evaluation and feline comparison. et al; Visceral mast
"^-"' cell tumors in dogs: 10
I Am anrm Hosp Assoc cases(1982-1997).I Am Vet Med-Assoc 216:222,20ii.-
30:445, 1994.
74. Theilen GH, Madewell BR: Tumors of the
42. Felts JR Fox PR, Burk Rl:_Thread and sewing needles digestive tract. In Theilen GH, Madewell
as gastrointestinal foreign BR (eds); Veterinary Cancer Medicine. phil"delpi;,
bodies iri the cat: A review of 64 cases.J An Vet i4ed Assoc i.;; Filigea uzo.
l{+rSO, 'ltgq.
75. MacDonald IM, Mullen H-S,Moroff
43. Basher AW, Fowler JD; Conservative versus surgical management SD; Adenomatous pollps of the duodenum
of gastrointesti_ rn cats: t8 cases(1985_1990). Am Vet
nal linear foreign bodies in the cat. Vet Surg 16:135;1987. J Med Assoc 2021647,'7993.
76. Happe RP, van der Gaag I,^Lamers
44. Lewis DD, Ellison GW: Intussusception in dogs and CBHW, et al: Zollinger_Ellison syndrome in
cats. Comp Contin Educ three dogs. Vet pathol I7:17i,1980.
9:523, 1987.
77. Moreland KI: Ulcer disease of the
45..PenninckDG, Nyland TG, Ly: .l al; Ultrasonographicevaluationofgastroin_ upper gastrointestinal tract in small animals:
I.lr Pathophysiology, diagnosis, and management.
t e sti n a ld i 5 e a seisn sma l l animals. Vet Radiol Jl:114, l9;0. 6r-ft.rii"'Earc vet pract 10:1265,
1988.

46. Lamb CR, Mantis p: Ultrasonographic features of intestinal 78. Murray M, McKeatins fl,
CI, et al: peptic ulceration in the dog: A clinico_
rntussusceptronrn 10
dogs. j Small Anim Pract 39:437,1998. !1]<e1
par hol ogi c als tud) . Ver R ei s l :44 t, l c 7l .
47. Longshore RC, O'Brien Dp, johnson GC, et al: Dysautonomia 79. zontne wJ, Meierhenry ER, Hicks
in dogs: A retro RF: perforated duodenal ulcer associatedwith
spective stud)'. J Vet Intern Med l0:103, 1996. mastocytoma in a dog: A case report. Am
J Vet Radiol Soc 1g:162, 1972.
48. Detweiler DA, Biller DS, Hoskinson 80. Middleton D], Watson AD), Culvenor
JJ, et al: Radiographic findings of canine lE; Duodenal ulceratron associated with
dysautonomia in twenty-four dogs. Vet Radiol Ultrasound"42iOS, gastrur-secretlng
pancreatictumor in a cat, J Am Vet Med
2001. Assoc l8i:461, 19g3.
49. Farrw CS: Radiographic appearanceof canine parvovirus 81. Burrows CF; Canine hemorrhagic gastroenteritis.
enterttts. .JAm Vct Med I Am Anim Hosp Assoc l3:451,
A sso c 1 8 0 :4 3 ,1 9 8 2 . 1977.

50. Nenzek JA, WalshawR, Hauptman 82. Haydcn DW, Van Kruiningen HJ: Lymphocytic_plasmacytic
JG; Mesentericvolvulus in the dog: A retro_ ententls in German
spectivestudy. J Arr Anim Hosp Assoc 29:357,1993. shepherddogs. J Am Anin Hosp Assoc iA,ris,
r9Sz.
51. Westermarck E, Rinaila-parnanenE: Mesenteric torsion B, M ar gul i s AR : Ex per i m ental i nfar c ti on
in dogs with chronic l :..- Ves t of s m al l bow e l i n c l o g s .A J R
pancreaticinsufficiency:21 cases(1978-1987). Am Vet 92;1080,1964.
I Med Assoc 195:1404,1989.
52. Arrick RH, Kleine LJ: Intestinalpseudoobstructionin t.nl"k,Y: A spectrum of hypueosinophilic syndromes
a dog. I Am Vet Med Assoc f1:, exemplifiedby six cats
1 7 2 :1 2 0 11, 9 7 8 . wth cosinophilicenteritis.Vet pathol Ig:tg8il, tSSt.

53. Moorc R, carpenter ,: Intestinarscrerosiswith pseudo-obstruction 85. Tanrs TR: Chronic feiine inflammatory
in trrrecdogs. bowel disorders: Il. Feline eosinophilic
J Am Vet Med Assoc 184:830,1984. enteritisand lymphosarcoma.Comp Contin
Educ Vet praci S,ain, ,rao.
54. Lamb WA, FranceMp: Chronic intestinalpseudo_obstruction 86. Grooters AM, Ililler DS, Wa.rd
in a dog. Aust Vet et al; Ultrasonographicappearanceof feline
I 7 l:8 4 , 1 9 9 4 . r l r nr c ntr r y l y m phom u. Vet R adj ol U _H,
l tr as oundJ 5:46g,1964.
55. ltrgens A-E;lnflamnratory bowel djsease:Current perspectives. 87. Penninck DG, Moore AS: Tjgy:ll AS,
Vet Clin North Arr et al: Ultrasonography of alimentary
Small Anim Pract 29:501,1999. lymphosarcoma in the cat. Vet Radiol Ultrasouncl
35,;;;,-;;;:;."
5,6. g'lnen TR:_Liver,spleenand pancrras.In O,Ilrien TR (ed): 88. Rivers I3J, Walter pA, Fee'ey DA, et
IladiographicDiagno_ al: Ultrasonographic features of intestinal
sis ofAbdominal Disordersin the Dog and Cat. phiJadelphia, adenocarcinomain five cats.vet nacliol uft*,"r"J
WB Saunders,1978. ts,36bli'992
M."|jk R Hunt Bellcnger CR, et al: Intra_abdominalcryprococcosrsrn two 89. Myers NC, Penninck DG; Ultrasonographic
?t _GB, diagnosisof gastrointestinalsmooth
d o g s. | 5 mrl l A n i m P ra cr40:387,l9qq. nr us c l er unr or si n r he dog. Ver R adi ol U l ti r s ound
:i l :s r ," r r 9al -
58- HelmanJlG, Oliver I III: pythiosis of tJredigestivetract in 90..Crystal.MA, Pennjnck DG, Matz ME,
dogs fron Oklahona. et al: Use of ultrasound,guidedfine_needle
/ Am Anim Hosp Assoc35:l I l, I999. aspiration biopsy and automated core
biopsy f., ,fr" ai"gr"ri, fbr gastrointestinal
diseasein snall aninrals.vet Radiol uf,r"r.'".ia
59. Miller RI: Gastrointestinalphycomycosis. ADr Vet Meci Assoc :],+Js, i99i.'"""
J 186:473,19g5.
9l..Gunther R, FeliceL/, Nelson RK, Franson
60. Graham .lP,Newell SM, Roberts GD, et al: Ultrasonographic AM: Toxicity ofa vitanin D. rodenticide
featuresof canine to dogs. J Am Vet Med Assoc 193:21I, 1988.
g a s tro i n re sri n p
rlyrh i o si s.Vet Radiol Ulr r r sound 4t:27j, 2060.
92. Morita T, Awakura T, Shimada A, et
61. Brodey RS: Alimentary tract neoplasns in the cat: A clinicopathologic . al: Vitamin D toxicosis in cats: Natural
survey of outbreak and experimentalstudy. Vet fr4ea
46 cases.Am J Yet Res27:74, 1966. I Sci SZ:g:1, iSS5.
93. Far TM, Simpson KW, Trasti S, et al:
62. Patniak AK, Liu S-K, Jonhson GF; Feline intestinai adenocarcinoma. Calcipotriol toxicity in a dog. J Small Anim
Vet pathol Pr ac t 39:581,1998.
l3:1, 1976.

63.. Patniak AK, Hurvitz AI, lohnson GF: Canine gastrointestinal Dobbs CE, Slaymen SA, et al: Calcipotriene
?1 ,H^1.__YR, poisoning in dogs. Ver
neoplasms.Vet Med 95:770,2000.
Pathol 14:547,1972.
95. Pear BL: Pneumatosisintestinalis:A reyiew.
64 Patniak AK, Hurvitz AI, lohnson GF: canine intestinal Radiology 207t13,1998.
adenocarcinoma and
carcinoid. Vet Pathol 17:149, 1980.

65' Feeney DA, Klausner ls, Johnston GR: chronic bowel

prmary intestinal neoplasia: A repoft of five cases. Am
obstruction caused by ffi Ouestions
J Anim Hosp Assoc lg;67,
I 9 8 2.
l. Serosalsurfacesof the small intestines
66. Gibbs C, PearsonH: Localizedtumors of the canine small would be expectedto
intestine:A report ot be poorly defined in which of the following conJitionsi
twenty cases.J Small Anim pract 27:506.19g6. (more than
one may be correct)
67. Bruecker KA, Withrow SJ: Intestinal leiomyosarcomas in
six dogs. I Am Anim A. A 9-year-oldfat dog presentedfor acute onset
Hosp Assoc 24:281, 1988. of vomiting,
pol)'uria, and polydipsia.
68. Kosovsky IE, Matthiesen DT, patnaik AK: Small intestinar B. A 14-year-oldiat'wiih anorexiaand severe
adenocarcrnoma in cats:
32 cases(1978-1985).I Am Vet Med Assoc 192:233,1988. weight loss.
C. A 4-month-old puppy with vomiting and palpaLle
abdomi_
69. Couto CG, Rutgers HC, Sherding RG, Rojko nal mass.
J: Gastrointestinal lymphoma in 20
dogs.I Vet Intern Med 3:73, 1989.
D. An obese 7-year-old cat, inappetent for
3 weeks with ic_
70. Pardo AD, Adams WH, McCracken MD, et al: primary jejunal
osteosarcoma terus.
associatedwith a surgicalspongein a dog. I Am Vet Med Assoc'196:935,
1990.
71. Bortnowsl<i HB, Rosenthal RC: Gastrointestinal mast cell tumors 2. Trte or False.The duodenum frequently
in two cats.J Am Anim Hosp Assoc 2g:271,1gg2.
and eosinophilia has a string_of_pearls
shapein the normal young dog and ;t, f.i
ini. can
72. J, Berg J, Sardinas lC, et al: prognosis for dogs with nonlymphomatous, De seen only on a barium upper gastrointestinal "pp."rance
-Cr-awshaw conliast study.
small intestinal tumors treated by surgical exiision. Am"Anim Hosp
l Asoc 34:451,
19 9 8 .
3. A l4-month-old male mixed-breeddog is
presentedfor inter_

:
 658 A B DO N/ E N -C O MP AN IOAN
N IM AL S
Figure 48*3O. Right lateralview of a 14-month-olddog with intermittent
l a ss is p a lp a b leSa
v om i t i n gf o r 5 d a y s .A n a b d o m in am . m e dog as that i n
F iq u r e4 5 - 3 1 .S e et h e a n swe rto Ou e stio n3 fo r in te r p r e ta tio n.
mittent vomiting of 5 days' duration. A mass in the abdomen and
gas-filledloops ofbowel can be palpated.Figures48-30 and 48-31
are right iateral and ventrodorsal survey views. What is your inter-
pretation of the radiographs,recommendationto the owner based
on your findings, and rationale for the recommendation?
4, An ll-year-old male Shih tzu has had chronic anemia and
melena for about 40 days.There is a tenseabdomen;pale mucous
I membranes; and dark, formed feces.Urinalysis and routine blood
t,'
chemistrieswere unremarkable (hemoglobin : 3.9 g/dl, packed
cell volume : 12o/o).A barium upper gastrointestinalstudy was
performed; Figure 48-32 is a right lateral view at 15 minutes,
Figure 48-33 is a ventrodorsalview at t hour, and Figure 48-34 is
a ventrodorsalview at 2 hours after barium administration. De-
scribe any significant radiographic abnormality, and list differential
diagnosticpossibilities.
5. Figures 48-35 and 48-36 are right lateral and ventrodorsal
survey abdominal radiographsof a l5-year-old neutered male cat
Figure 48-31. view of same dog as that in Figure48-30
Ventrodorsal
Figure 48-32. Right lateralview at 15 minutes after bariumadministration
i n an 11-year-olmal
d eS hi htzu w i th chroni canemi aand mel e na.S ee Oues ti on
4 for more historyand laboratoryresults.Same dog as that in Figures48-33
and 48-34. See the answerto Ouestion4 for interpretation.
reported to be ill for 5 days with dark diarrhea. On physical
examination, the cat is depressed,and distended bowel loops are
palpable. Describe the appearanceof the gastrointestinaltract.
What is your interpretation?
6. A l-year-old neutered male seal-point Siamesecat had a 1-
month history of pyrexia, weight loss, and general debilitation. The
owner reported recent onset of diarrhea. The cat was depressed
and lethargic with thickened, painful bowel on palpation. Addi-
tional testsincluded fecal (negative),total serum protein = 8.7 gl
dL, and negativeserology for feline leukemia virus and toxoplasmo-
sis. Figures 48-37 and 48-38 are right lateral and ventrodorsal
views made 3 hours after barium administration. Describe any
radiographic abnormalities demonstrated by the barium study. List
possibleexplanationsfor observedabnormalities.
7, What is one of the most common causesof technically inade-
quate barium upper gastrointestinal studies?
Figure 48-33. Ventrodorsalview at t hour after barium administration.
Samedog as in Figures48-32 and 48-34.
 The SmallBowel 659

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
male cat that was ill for 5 days with dark diarrhea.Distendedbowel loopsare
palpable.For interpretation see the answerto Ouestion5. Same cat as that in
Fiqure48-36.
Figure 48-37. Rightlateralview at 3 hoursafter bariumadministrationin a
1-year-oldcat with a l-month history of pyrexia,weight loss, ano generai
debilitation.See Ouestion6 for additionalhisioryand lab'oratory
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
Figure 48-38. Ventrodorsal
view at 3 hours after bariumadministration.
8. Give the reason why there may be no abnormalities from an
intestinal obstruction on survey abdominal radiographs.
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?
CHA P T E R
49
The Large Bowel
I Darrvl N. Bierv
I lmaging options for large
I bowel disease
Survey and contrast radiographic procedures have been used to
assessmany colonic conditions.l-3 After a survey radiographic ex-
amination, however, endoscopy (colonoscopy) now has largely re-
placedthe radiographiccontraststudiesof the colon. Most colonic
diseasesare diagnosed using endoscopy,especiallywhen a flexible
endoscopeenablesvisualization of the transversecolon, ascending
colon, and cecum.a
Ultrasound has become a sensitive and practical imaging mod-
ality that is usually less time consuming than many radiographic
contrast studies of the colon; it provides additional and comple-
mentary information to the clinical, endoscopic, and survey radio-
graphic findings.' Although air and fecesin the bowel are limiting
factors for ultrasound studies, an ultrasound examination can as-
sess near-fieid bowel wall thickness and symmetry, mural and
extramural bowel masses,the regional lymph nodes, intussuscep-
tions, and other abdominal viscera. Needle aspiration and biopsies
of the colon can also be obtained using ultrasound-guided tech-
niques.6't In addition, new techniquesof endoscopicsonography
are now beginning to be used for detailed evaluation of mural and
extramural colonic structures.
Samecat as that in Fioure48-37
10. Tiue or False. Small bowel wall thickening is more reliably
determined by palpation and ultrasonography than by survey radi-
ography.
Answers begin on page 727,
Less commonly used imaging techniques for colonic disease
include rectocolonic lymphangiography, mesenteric angiography,
and colonic transit scintigraphy. These techniques enable assess-
ment of anatomic or functional abnormalities but require special-
ized equipment and expertise.8-l0
I Normal radiographic anatomy
The large bowel of the dog and cat is composed of the cecum,
colon, rectum, and anal canal (Fig. 49-1). The cecum,a diverticu-
lum of the proximal colon, has different anatomic and radiographic
appearancesin the dog and the cat (Fig. 49-2).t The canine cecum
is semicircular (corkscrew or C-shaped) and compartmentalized
with a cecocolicjunction and normaliy containssome intraluminal
gas. The intraluminal gas and characteristic shape enable easy
recognitionof the cecum in the right midabdomen on most survey
radiographs. The feline cecum, however, is usually not visible on
survey radiographs. It is a short, cone-like diverticulum of the
colon with no distinct cecocolic junction and no compartmental-
ization; it rarely contains gas.
The colon of the dog ind the car, the longest segment of the
large bowel, is a thin-walled distensible tube thar is divided into
 The LargeBowel 661

Figurc 49-1. Survey lateral /A/ and ventrodorsal/B/ radiographsof a normal

. h e la r g eb o we l is d ivid e din to th e ce c um (1),ascendi ngcol on
c a n i n ea b d o m e n T
(2),transversecolon (3),descendingcolon (4),hepaticflexure(5),splenicflexures
(6),rectum (7),and analcanal.Note the admixtureof gas and feces presentin the
cecum, colon, and rectum. In B, the descendingcolon is displacedtoward the
right by a normallydistendedurinarybladder.

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

ascending, transverse, and descending parts. These divisions are

easily recognized on survey abdominal radiographs based on their
shape, size, and location. The distal ileum enters the ascending
colon from a medial direction via the ileocecal sphincter. This
circular sphincter is usually not visible on survey radiographs, but
it is usually easy to identift as a filling defect when barium is
presentin the lumen of the proximal colon. The colon has a shape
similar to that of a question mark or a shepherd'scrook (seeFig.
49-1). The iunction betweenthe ascendinqand transversecolon is
the hepatic or right colic flexure, and the junction between the
t
| //,
transverse and descending colon is the splenic or left colic flexure. Mesentery,
The ascendingcolon and hepatic flexure are located to the right of rf lymphnodes,
*r and -<
midline. The transversecolon, which passesfrom right to left, lies
smallbowel
cranial to the root of the mesentery. The splenic flexure and
proximal descending colon are located to the left of midline. The
distal descendingcolon coursesto the midline and enters the pelvic
canal to become the rectum. The rectum is the terminal portion
of the colon, beginning at the pelvic inlet and ending at the
anal canal.
An understanding of the anatomic relationship of the large
bowel to other viscera is extremely important for the radiographic
recognition of diseasesof the large bowel and adjacent organs
(Fig. 9-3). The ascendingcolon lies adjacentto the descending
duodenum, right limb of the pancreas, right kidney, mesentery,
and small bowel. The transverse colon lies adjacent to the greater
curvature of the stomach, left limb of the pancreas, liver, small
intestine, and root of the mesentery. The proximal descending
colon lies in close proximity to the left kidney and to the ureter,
spleen,and small bowel. The midportion of the descendingcolon
lies adjacent to the small bowel, urinary bladder, and uterus.
Becauseit is lessfixed, the midportion of the descendingcolon has
a varietv of normal positions in the caudal left abdomen. Normal
variations a.e .uor.d by various amounts of ingesta within the
bowel, the degreeof urinary bladder distention, and the amount
of intra-abdominal fat. Some dogs appear to have an excessof
length of colon. This finding, calledredundantcolon, is considered
a variant of normal and is not clinically significant.r'3'rr
Frequently, the distended urinary bladder displacesthe descend-
ing colon toward the midline or to the right of midline (see Fig.
49-l). The distal portions ofthe descendingcolon and rectum are
also closely associatedwith the urethra, the medial iliac and sacral
lymph nodes, the prostate or uterus and vagina, and the pelvic Figure 49-3- Visceraadjacentto the large bowel, on a ventrodorsalradio-
graphi cvi ew , may causeanatomi c-radi ographi vari
c ati onsth at may be al ter-
diaphragm.
ations indicativeof diseaseor variantsof normal.Arrows, Usual directionof
l argebow el posi ti ondi spl acement w hen an organenl arge si s ee Fi g. 49-9).
{FromO'B ri enTR : R adi ographiDci agnosi of s A bdomi nalD i s ordersi n the D og
I Radiographictechniques and C at.D avi s,C A , C ovel P
l arkV eteri narv,
1981.)

I of large bowel evaluation

Survey radiography
Becausefecesand gas produce contrasting radiographic opacities
and are usually present in the large bowel, a part or all of the large
bowel is identifiable on survey radiographs of the abdomen. The
different body positions used for survey radiography distribute
intraluminal gas to different parts of the large bowel, largely be-
causeofgravity. Thus, gasis usuallypresentin the more nondepen-
dent portions of the colon. When present, foreign bodies (e.g.,
pieces of bone, safety pin, wire) are easily recognized on survey
radiographs. The colonic mucosal pattern cannot be evaluated
from survey radiographs.
When the large bowel is evaluatedradiographically, it is essential
that the entire abdomen and pelvic area be included on two
orthogonal radiographic views. The urinary bladder should be
empty. Rectal examination, vigorous abdominal palpation, aero-
phagia from restraint and struggling, and enemas before survey
radiography may increasethe amount of gas or fluid present within
the colon and in other parts of the gastrointestinal tract. Although
an abnormaiity in position, size, or shape of the large bowel may
be seen on survey radiographs, it may not be a significant finding,
and a diagnosis may not be possible.
Compression radiography
Compression radiography of the abdomen is a simple technique
that may aid in further delineation of the presence of a lesion.
When the colon is compressedwith a wooden or plastic spoon or
paddle, adjacent bowel or masses are displaced or compressed,
which enhances radiographic detail (Fig. a9-a). More definitive
radiographic evaluation of the large bowel usually requires a con-
trast study using barium sulfate suspension (barium enema), air
(pneumocolon), or a combination of barium sulfate suspension
and air (double-contraststudy).
Barium enema
After survey radiographs, the barium enema is the most commonly
used radiographic study for the examination of the large bowel.
Currentiy, a barium enema is most indicated when (1) narrowing
of the lumen prevents passageof an endoscope, (2) limitations of
 The LargeBowel 663

Figure 494' A 5-year-oldneutereddomesticshorthairedfemale cat. A, survey radiograph. Thereis an abnormalsoft-tissuemass(arrows)interposed

the descendingcolon and the urinarybladder'At surgery,the mass was found io be i uierine between
stump pyometra.a-s'ri"uv lateralrecumbentradiographof the
abdomenwith a compressionpaddleapplied.The mass appearsfixed and separatefrom the
descenai'ng-6oio"-;.or'riia"ryotaoaer.C Surveylateralradiographof
the abdomenafter a partralpneumocolonstudy via retrogradeintroductionoi gas. The aoft-t,rau"
mass (uterinestump pyometra)js visualizedas an extramural
mass. Feceswere not removedbeforethe contraststudy was conoucteo.
664 A B DO N/ I E N -C O MP AN IOAN
N IMA L S
the endoscopeprevent examinationof all of the colon and cecum,
and (3) a mural or extramural lesion is suspected,and the mucosa
is found to be normal on endoscopicexamination.aSurveyradio-
graphs should be made not only as a first diagnostic step, but
also prior to the contrast study to determine correct radiographic
exposuretechniquesand to ascertainadequatepatient preparation
for the contrast study. For a high-quality diagnostic study, the
colon should be thoroughly cleansed prior to the contrast study.
This is best done by withholding food for 24 to 36 hours, and by
cleansingthe colon with both an orally administeredcathartic and
warm water enemasprior to the procedure.The colonic mucosa
and lumen should be free of fecal material with a clear effluent
visible on an enema immediatelyprior to the study. Generally,the
radiographictechniqueshould be increasedby 6 to 8 kVp over the
surveytechniquewhen barium is used.Although the techniquesof
doing a contrast study may vary, barium at room temperature is
administeredthrough an inflatable cuffed catheter placed in the
distal rectum to prevent the barium from leaking from the colon,
and to obtain adequatedistention of the colon.'' " 'r Generalanes-
thesia is almost alwaysnecessary. Micropulverizedbarium suspen-
sion is the contrast medium of choice for obtaining a smooth
coating of the mucosal surface.The colon should be slowly filled
with barium by means of a gravity system, and preferably with
fluoroscopicobservation.Becausefluoroscopicequipment may not
be available and the volume of barium needed to fil1 the colon is
extremelyvariable,the contrast medium should be given in several
small increments until the desired effect is seen radiographically.
Usually the barium dose is 7 to 15 ml of barium per kilogram
body weight. Multiple radiographicviews-that is, left lateral,ven-
trodorsal, and ventral right-dorsal left and ventral 1eft-dorsalright
oblique views-should be made when the colon is distendedwith
barium and again after evacuationof the barium from the colon.
The detection of subtle rnucosal lesions may be enhancedby a
double-contraststudy. In most instances,this is done by removing
as much of the barium as possibleand inflating the colon with
room air through the catheter.
When distendedwith barium, the normal colon has a smooth
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
provides the most detailedvisualizationof the mucosalsurface.
A variety of radiographicappearancesresult from adherenceof
barium to mucus, clumping and flocculationof barium, and filling
defectsof fecesthat are either within the lumen or attachedto the
wall. The colon of the doe and the cecum and colon of the cat
have lymph follicles in the mucosa, which appear as spicules on a
barium enema study, or as pinpoint radiopacitieswhen visualized
en face with a double-contrast study. These normal follicles must
be differentiated from small ulcers.
The large bowel cannot be properly evaluated following oral
administration of contrast medium becausethere is usually inade-
quate large bowel luminal distention; intraluminal filling defects
due to fecesalso occur frecuentlv.
Complete large bowel contrasi studiesare time consuming and
must be done meticulouslyto assess the mucosa,wall, lumen, and
adjacent viscera as well as to avoid artifacts, complications, and
messes,such as contrast medium on the veterinarian,equipment,
and patient. Partial large bowel contrast studies, which are less
thorough, quicker, and easier,may be performed with the introduc-
tion of small amounts of air or barium into the rectum via dose
syringe.Thesestudiesdo not allow visualizationof the entire large
bowel nor of small lesions,such as mucosalirregularities;however,
they may enable visualization of large intraluminal lesions and
differentiationof the colon from adjacentorgans and masses(see
Fig. 49-aC).
Gomplications associated with contrast studies
Complicationsrelated to contrast studiesof the colon may occur.
The most seriouscomplication is perforation and subsequentperi-
tonitis (Fig. 49-5). Rupture can occur from a cieansingenema,
improper selectionor use of a barium enemacatheter,and overdis-
tention of weakenedor diseasedbowel, or after a biopsy.ra-','If
colonic perforation is suspected,a l5o/o to 20o/oconcentration of
nonionic aqueousiodine contrast medium can be substitutedfor
the barium, but mucosaldetail will be significantlydiminished.r,
A common complication that is inconsequentialis retrograde
filling of the distal small bowel; such reflux may obscurevisuiliza-
tion of the colon. This complication has been reported in about
one third of dogs and may occur without overdistentionof the
colon.rr Spasm,which is usually transient, may also occur when
the contrast medium is cold, when narcotic premedicationsare
used,or when the wall is irritated by the catheter(Fig. 49-6).
I Ra d io g r a p h ic fin d in g s in l arge
I bowel disease
Disease involving or adjacent to the large bowel may produce
radiographicalterationsin size,shape,location, and radiopacity.ra
Although function cannot be evaluated radiographically, the quan-
Figure 49-5, Lateralradiographof a S-year-oldmale lrish
setteri n w hi ch perforati on
of the col onoccurredduri nga bar-
i um enemastudy.Thi s compl i cati on may oc c ur s ec ondaryto
i mpropertype and use of a catheteror to di se as eof the c ol on.
The dog had a 4-monthh story of w ei ght l os sand s trarni ng to
defecate. A t necropsy, chroni cprostati tiws i th adhes i ons
to the
col onand a ocal i zedoeri toni tiw
s ere evi dent .
 The LargeBowel 665

'"
"11&lrrrail
ti:-4
du:::iltl

**

,.',*ljj
1" ,a'

,{ui"*i* i
i-;;-:
ii *-,'-;-'"-'
-";;;
iiel

.r l

Figure 49-6' Narrowingand inegularityof the descendingcolon are,presentimmediately

cranialto the air-inflated
cathetercuff. This was a spasm /A/ and was
transientbasedon a subsequentradiograph(B) madeseverJlminuteslater.

tity or location of fecesmay suggestimpaired motility. Most radio-
graphic findings in specificlarge bowel diseasesare not pathogno_
monic. Many different diseaseshave similar radiographii findings,
and any particuiar diseasemay havea spectrumofdifferent upp.i._
ances.In addition, parasitic,dietary,and other inflammatory causes
of large bowel disease commonly have no visible radiographic
abnormality.
In the normal large bowel, the colon containsmost of the feces,
with small amounts of or no fecesin the rectum (seeFig. 49_l).
The diameter of the normal colon varieswith the amouni of feces
present and individual defecationhabits. As a rule of thumb, the
diameterof the normal colon should be lessthan the lensth of L7.r
Colonic impaction is characterizedradiographicallyb/ accumu-
. left
lation of the feces,which are more radiopique than normal as a
consequenceof constipation,obstipation, or megacolon.Chronic
impaction can also result in generalizedeniargemint of the colon.
Localizeddilation of the colon is usually relited to impaction or
localizeddiseases suchasmechanicalobstruction(e.q.,ile'ocolic
and
cecocolicintussusception,cecal and colic volvulus] stranqulation
by ruptured duodenocolic ligament), narrowed pelvic can"alfrom
fracture,intramural or extramuralcolonic tumorlFig. 49-7), stric_
ture, and foreign body.
Abnormal generalizedenlargementof the colon is commonly
referred to as megacolon,a condition causedby mechanical or
functional obstruction and characterizedby diffuse colonic dilation
with ineffective motility. Megacolon may be idiopathic or associated
wlth numerous underlying causessuch as (l) chronic constipation
and obstipation,(2) feline idiopathic (3) spinal uno-u_
lies (e.g.,caudaequina syndrome,sacroiccygeal
-.gu.oior,, aqenesisin Manx
cats),(4) neuromusculardisorders(e.g.,felinJdysaitorro-ru, ug"r,-
glionosis,.or Hirschsprung'sdisease
[Fig. 9_g]), (5) metabolic
drsorders( e.g.,hypokalemia,hypothyroidism),(6) surgicaluretero_
colic diversion techniques,(7) perineal hernia, and
3.r72l fg) anorectal
congenitalanomalies.r'
Congenitalanomaliesof_thelarge bowel are rare in the dog and
.
the cat. Anomalies reported includle imperforate anus, atresia recti,
atresiacoli, fistulation, diverticula, duplication of the 1argebowei
and rectum, and a short, straight colon with the cecum in the
hemiabdomen.1,3,22_28
The sizeand shapeof the colon may alsobe alteredby numerous
,
chronlc mflammatory diseasesof the large bowel and adjacent
viscera. These inflammatory changesmay'result in localized
or
generalizedirregularity and ulceration of the mucosawith
diverti,
cula,adhesions, or shorteningof the colon.
Abnormal location of the lirge bowel is a common radiographic
alteration seen with large bowil diseasein the dog and c"at.'Al_
tnougn therels somenormal variabilityin the locationof the large
bowel, mass lesions,particularly those of organs adjacent to tfre
colo^n,cause displacementof the cecum, .olo.r, o, rectum (Fig.
49-9; see also Fig. 49-3 and Chapter 39). Massesor enlarsemerit

Figure 49-7. Survey lateral recumbent radiographof the

abdomen of a g-year-oldfemale, neutered mrxed-breeddog
wr t h 5 m o n t h so f p r o gr e ssive d ifficu ltyu r in a tin ga n d str a in in g
to defecate.The stools were flattened,and a rectalmass was
pa l p a b l eT. h e m a s s w ith in th e p e lviswa s a fib r o le io m yo ma
c a u s i n gp a r t i a lc o l o n i co b str u ctio na n d m e o a co lo nUn . r e la te d
L/ - S 1 s o o n d y l o s rdse fo r m a n sis p r e se n r .

j-
- : * . _; - ^, :r y:i -
666 A B DO N/ E N -C O MP AN IOAN
N IM AL S

Fi gure 49-8. General i zedmegacol oni s pr es ent.Thi s 5-

month-ol dfemal e mi xed-breed dog had functi onaland hi s to-
l ogi cevi denceof H i rschsprung's
di sease.

Figure 49-9. Terminalcolon and rectal

dis p l a c e m e nbt y a d j a ce n to r g a n e n la r g e -
m en t . A , V e n r r aol i s p l a ce m e ' or tf th e te r -
m in a lc o l o na n d r e c t u mco m m o n lyr e su lts
f rom m e d i a l i l i a c ( pr e vio u sly ca lle d
sublumbar or external tliac lymph nodes)
and s a c r a ll y m p h n o d e e n la r g e m e n t. Al-
t hou g h l e s s c o m m o n , a h e m a to m a ,a b -
s c e s s , o r t u m o r m a y p r o d u ce sim ila r
dis p l a c e m e n ta l t e r a t i o n s.B, Do r sa ld is-
plac e m e n to f t h e r e c t u m co m m o n lyr e -
sults from enlargementof the prostate,
t he u t e r u s ,t h e v a g i n a ,o r th e in tr a p e lvr c
urin a r yb l a d d e r(.F r o mO' Br ie nT R: Ra d io -
grap h i cD i a g n o s ios f A b d o m in aDiso l rders
in t h e D o ga n d C a t .D a vis,CA, Co ve llPa r k
V et e r i n a r y1 9 8 1 . ) B
 The LargeBowel 667

Figure 49-1O, A 4%-month-oldmale Siamese cat with ileocolic

in t u s s u s c e p t i oNn o. t eth e r a d r o lu ce n t gd e fe cta n dth e co il ed_spnng
fillin
a p p e a r a n ccer e a t e db y th e jn tu ssu sce p tu b me in go u tlin e db y
bari um.

of the.uterus,prostate,and lymph nodes (mesenteric,para_aortic, Sp-. dogs,appear,to have an excessivelength of colon.

and iliac) commonly alters the position and shape of tn. hrg. . This
nnqrng, called redundant colon, seemsto be a variant
DOWel. of normal
and is not clinically significant.
It is important to r-ecognizethe radiographic differences in ap_ tr4any large bowel diseasesexhibit radiographic changes
pearancefor lesions of the large bowel that ire intraluminal, intra- in the
colon that are similar to those often presen"tin other parts
mural, and extramural. These classifications as to site of origin of the
gastrointestinaltract. These-conditioniinclude (1)
allow differentiation of conditions such as foreiqn bodies, intussis_ foreign bodies,
(2) obstruction, including ileocolic (Fig. a9_10)
ception,inflammation, and benign or malignanitumors. For exam_ and cecocolicin_
tussusception_(Fig.49-ll), volvulus, ind strangulation,
ple, a lesion that is plaquelike is intramuJal and arises from the (3) in_
tlammation (Fig. a9-12), (4) stricture (Fig. a9_I3), (5)
mucosal or submucosal tissues.An extramural mass usually causes neoplasms
(Fig..a9-14), (6) perforation, (7)
extrinsic narrowing of the lumen, displacementof the bowel and adhesiois,and (S) diverticula or
hernra (l,rg. 49-151.z"to
adjacentviscera,or both. In most diseasesof the large bowel, particularly those
that are

Figurc 49-11- A 14-month-oldmale Beaglehad intermittentdiarrheawith

shreds of mucosaand
blo o d I n t h e s t o o l f o r 5 m o n r h s.o n th e ve n tr o d o r savie r w d u ri nga bari umun".i L*.ri ,nut,on,u
c ec o c o l i ci n t u s s u s c e p tjoisnvjsr b lea s a r a d io lu ce nfjllin
t gd e fe ct.N otethat the remai nder
of the l arge
bowel, ileocolicjunction(arrow),and distal ileum are nJrmal.The cecocolicintr..u..upti-on
i nuo not
bee nv i s i b l eo n t w o p r evio u sb a r iu mu p p e rg a str o in te stintraal ctstudtes.
I

E
:
6 68 A N IMA L S
A B DO M E N -C O MP AN IO N

Figure 49-12, Barium enema ex-

ami nati oni n tw o dog s ,one w i th gen-
eral i zedcol i ti s/A , and the other w i th
Jocalizedco itis /8./.Note the nondis-
tensi bl edescendi n cg ol onand c ec um
and shorteni ngof t he c ol on i n the
more advancedand general i z ed di s -
ease.The l ocaLi zed c ol i ti si s c harac ter-
i zed by nondi stens i bi l iand ty muc os al
of the di s talporti onof the
i rregul ari ty
descendi ng col on.

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

Figute 49-14. A bariumenemasrudy

rn a 6_year-old female
Germarnshgg|gJd dog. An jntratuminal
,.r, fjr-."1 ir-ru"n
as , ap o l y p o j df i l l i n gd efe crin th e m r d p o r tio n
i;;l;;";.d ,;g
c o l o n .T h e m a s sw a s lym p h o m ao f th e co lo n"f.

not extramural, a contrast study is required

for detection and for stagesof bowel inflammation have
decision making as to tl no abnormal radiographic find-
ihi;te;;r';'ftiil.ii:1,lf:::Ji"3n:'"li::;;T;* rngs.
A severe form of inflammatory
study) in largebowel diseaieinclude disease in the dog, known as
tf l i.*g"f".ity of the barium_ ulcerative colitis, has a spectrum
interface, (2)-spasm of_the bowel"l,r_.,i, of radiographic findings that
TT":..
complete 1:; partial or consist of mucosal and suLmucosal
occlusion of the. bowel.lumen, (4) outpouching ,1..;; ,;;r;icity, rigidity, and
of the
taisplacement shorteningof th-ecolon (seeFig.
bowel wall due to a hernia or ai"..ticuirr-, 49_i;;.-"'
fsJ of
bowel,.and (6) perforation with peritonitir- ' ' ' - Narrowing of the large bowel lumen
results trom spasm or
Simiiar to the alteratio constriction due to neoplsia, scar
,;;r* ;;;i;;.t t.urr_u to th.
trast
study
n,did;;;;';:lff i:il::fi I 'i'fffirrtL,a:T; bowel wall. Unlike consiriction,
ts secondaryto the barium.enema
spasm-t;;;i;;;"rd frequently
mucosal irregularity are commonly associated techniq". fr.. fig. 49_6). When
with s.uere lo.al evaluatinga constrictionwith the
inflammation, other causesinclude Lrl.ity, use of a barium enemaexamina_
,.ff." mechanism, and tron, the base and leneth of_the
idiopathic factors. Bowel inflamm",i"" defect, ifr. _*"*f surface, and
t11..,-iypf,iitisand colitis) the mural involvement"should
may occur with_generalizedor regional u..u, be ;ilJ^i;-F,& 49_13). Most
of bowel wall thick_
ening due to edema and small u'icerations. of the large bowel are producedby
Frequently, the acute :::^:T1:!"", (usually
carclnoma and lymphosarcoma),but benign ffitur_,
iir.ur,. .u.t as ade_

Figure 49-IS. A 17-month_old female,neuteredmixed-breeddog had a painful

abdgmgn and.lethargyafter ftghttngwith
a largerdog. In survey laletat(A) and
radiographs,a.tocalizedanO AituteJt'"ces_irrred
:::L1d,9t-t^"1^lq|
oescendrng sesment of the
colon was seen This representsa partial
i n g u i n ahl e r n i a . otitruction, withjn a left
 AN IM AL S
6 7 | 0 A B DO M E N -C OMP AN IO N

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.
J Am Anim Hosp Assoc 27:97,1991.
27. Schlesinger DP, Philbert D, Breur GJ: Agenesis of the cecum and the ascending
and transverse colon in a twelve year old cat. Can Vet | 33:544, 1992.

Figure 49-16. Postevacuation ventrodorsalradiograph

of a bariumenema. 28. Shinozaki JK, Sellon RK, Tobias KM, Chamberlain K: Tubular colonic duplication
Normallongitudinal mucosalfoldsof the colon(curved
arrow)andanabnormal in a dog. I Am Anim Hosp Assoc 36:209,2000.
mucosal pattern(straight
arrow)atevisualized.
Theabnormalareawaslocalized 29. Guffu MM, Wallace L, Anderson NV Inversion of the cecum into the colon of a
colitisandwas notvisibleon otherradiographs withthe coon dis-
obtained dog. I Am Vet Med Assoc 156:183,1970.
tended withbarium.
30. Kolata RJ, Wright JH: Inflammation and inversion of the cecum in a cat. I Am
Vet Med Assoc 162:958,1976.

noma, scar tissue, eosinophilic colitis, and ulcerative colitis may
mimic the radiographicfindings of a malignant lesion.
References
1. O'Brien TR: RadiographicDiagnosisofAbdominal Disordersin the Dog and Cat.
Davis, CA, Covell Park Veterinary, 1981.
2. Farrow CS, Green R, Shiveley M: Radiology of the Cat. St. Louis, Mosby, 1995.
31. Lansdown ABG, Fox EA: Colorectal intussusception in a young cat. Vet Record
19i429,1991.
32. Carberry CA, Flanders ]A: Cecal-colic volvulus in two dogs. yet Svgery 22t225,
1993.
33. Drobatz KJ, Hughes D, Hill C, Walker L: Volvulus of the colon in a cat. J Vet
Emerg Crit Care 6:99, 1996.
34. Hassinger KA: Intestinal entrapment and strangulation caused by rupture of the
duodenocolic ligament in four dogs. yet Svrg26:275, 1997.

3. Kealy Kl, McAllister H: Diagnostic Radiology of the Dog and Cat, 3rd ed. 35. Morris EL: Pneumatosis coli in a dog. Vet Radiol Ultrasound 33:154,1992.
Philadelphia, WB Saunders, 2000.
36. Bolton GR, Brown TT: Mycotic colitis in a cat. Vet Med Small Anim Clin
4. lergens AE, Willard MD: Diseasesof the large intestine. In Ettinger SJ, Feldman 67:978,1972.
EC (eds): Text Book of Veterinary Internal Medicine, 5th ed. Philadelphia, WB
37. Birchard SL Couto CG, Johnson S: Nonlymphoid intestinal neoplasia in 32 dogs
Saunders,2000, p 1238.
and 14 cats. I Am Anim Hosp Assoc 22:533, 1986.
5. Lamb CR: Recent developments in diagnostic imaging of the gastrointestinal tract
ofthe dog and cat. Vet Clin North Am Small Anim Pract 29:307,1999. 38. Slawienski M), Mauldin GE, Mauldin GN, Patnaik AK: Malignant colonic neopla-
sia in cats. J Am Vet Med Assoc 211:878, 1997.
6. Homco LD: Gastrointestinal tract. In Green R (ed): Small Animal Ultrasound.
Philadelphia, Lippincott Raven, 1996. 39. Sealer RJ: Colorectal pollps ofthe dog: A clinicopathologic study of 17 cases.j
Am Vet Med Assoc 174172,1979.
7. Penninck DG: Ultrasonography of the gastrointestinal tract. In Nyland I Mattoon
40. Welches CD, Scavelli TD, Aronsohn MG, et al: Perineal hernia in the cat: A
J (eds): Veterinary Diagnostic Ultrasound. Philadelphia, WB Saunders, 1995.
retrospective study of 40 cases.J Am Anim Hosp Assoc 28:431, 1992.
8. Becker M, Adler L, Parish IF: Rectal lymphangiography in dogs. Radiology
91:1037,1968.

9. Gomez IA, Korobkin M, Lawson TL, et al: Selective abdominal angiography in ffi Ouestions
the dog. J Am Vet Radiol Soc 14:72, 1973.

10. Krevsky B, Somers MB, Mauere AH, et al: Quantitative measurement of feline 1. If inflammatory diseaseof the large bowel is suspectedclini-
colonic transit. Am i Physiol 255:G529,1988. cally, which of the following examinations would usually be indi-
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
similar anatomic and radiographic appea-rances.
3. Which of the following is not recommended prior to a barium
enema radiographicstudy?
A. Withhold water for 8 to 12 hours.
B. Withhold food for 24 to 35 hours.
C. Empty the urinary bladder.
D. Administer gastric lavagesolutions.
E. Administer warm water cleansing enemas.
4. Tiue or False.The large bowel cannot be fully evaluatedradio-
graphically with an upper gastrointestinal barium study.
B. Intraluminal mass in the descendins colon
C. Old pelvic fractures with maluniJn and secondary nar_
rowing of the descendingcoion
D. Perineal and abdominal hernia
E. Idiopathic megacolon
9. In the same cat (refer to euestion B and Figs. 4g_1g, 49-20,
49-21, and 49-22), a barium enema and double--contrastbarium
enema were done. Based on the contrast studies, which of the
following.conditionsis present?Note: The intraluminal filling de_
rects are clue to feces.

5. Ulcerative mucosal lesions of the colon are best visualized

radiographically with which of the following techniques?
A. Survey radiographs
B. Pneumocolon
C. Barium enema
D. Double-contraststudy
E. Survey radiographs made with compression

6. In dogs and cats, the most common reason for displacement

of the descendingcolon is:
A. Distendedurinary bladder (full bladder).
B. Enlarged right kidney.
C. Enlarged prostate.
D. Pancreatitis.
E. Congenital anomaly.

7. Most constrictive and infiltrative lesions of the colon are caused

by which of the following?
A. Tumor
B. Colitis
C. Tiauma from prevrous enemas
D. Perineal hernia
E. Prostatic infection

8. Since being adopted as a stray several weeks earlier, a female

domestic shorthaired cat has had recurrent episodes of constipa-
tion. Based on two survey radiographs of the abdominal and
pelvic regions (Figs.49-17 and 49-18), what is your radiographic
diagnosis for the most likely causeof the constipation?
A. Foreign body of the descendingcolon Figure 49-18

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

A. Normai feline cecum and colon

for the cecum and ascending portion
B. Intraluminal massin descendingcolon, probably tumor of the colon? Note: The
intraluminal filling defects u.Jd,r. to feces.
C. Partial obstruction of descendingcolon iecondaiy to previ_
A. Normal feline cecum and ascendingcolon
ous trauma
B. Cecocolic inversion
D. Perineaihernia with partial obstruction of the descending
C. Cecal aplasia
colon
D. Redundantcolon
E. Colitis
E. Colitis

10. In the same cat (refer to euestions g and 9 and Figs.

49_19,
49-20, 49-21, and 49-22), what is your radiographic inteipretation Answers begin on page 227.

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
is the purpose of this chapter to provide the veterinary student
and practitioner with a limited reference for the anatomy of the
more frequently radiographed regions in the dog and horse.
By inclusion of labeled radiographs of selectedareasof clinically
normal animals, we have attempted to provide basic resourceinfor-
mation for veterinarians in support of their more effective utiliza-
tion of the roentgen-signmethod of radiographic interpretation.
For more detailed information, we refer readers to comprehensive
textbookson radiographicanatomy.r,'?
The radiographic nomenclature used in this chapter is that
approved by the American College of Veterinary Radiology in
1983.3The xeroradiographs of the equine limbs presented in this
chapter(Figs.50-51 through 50-71) havebeentaken from previous
3. Smallwood lE, Shively Ml, Rendano VT, Habel RE: A standardized nomenclature
for radiographic projections used in veterinary medicine. Vet Radiol 2:9, 19g5.
4. Smallwood JE, Shively MJ: Radiographic and xeroradiographic anatomy of the
equine carpus.Equine Pract I:22, 1970.
5. Smallwood JE, Holladay SD: Xeroradiographic anatomy of the equine digit and
metacarpophalangealregion. Vet Radiol 28:166, 1987.
6. Shively MJ, Smallwood JE: Radiographic and xeroradiographic anatomy of the
equine tarsus. Equine Pract 2:19, 1980.
7. Zontine WJ: Canine dental radiology: Radiographic technic, development, and
anatony of the teeth. J Am Vet Radiol Soc 16:75, 1975.
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:
. ". ,"'

Figwe 5O-1. Mediolateral Radiograph of Canine

S houl der Joi nt.
1. Tracheal carti l ages
2. S pi neof scapua
,
,lillill;,,tl,l:, 3. S upraspi nous fossaof scapul a
4. Infraspi nousfossaof scapul a
tr n ^.^- ^^ vr
v,, ruovurot-
^+ ^^^^,
l" ll',,'ill
I
6. Gl enoi dcavi tyof scapul a
7. Manubri umof sternum
8. H eadof humerus
9. P roxmal physi sof humerus
10. R adol ucentareacreatedby concentrati on
of fat,
caudalro sho.l de'.oi ^t capsLle
11. D aphysi sof humerus
1, l ^ i a r i l h a .., lrr n r a n va

13. Greatertubercl eof humerus

14. C oracoi dprocessof scapul a
15. S upragl enoitubercl
d eof scapua

, .lll'1l.i.tl.'

Fig u r e 5 O - 2 . C a u d o cr a n ia l Ra d io g r a p h o f Ca n in e S houl der

Joint. r:r6tlr.,rrlt!l
iiili4ll ilitrrl
1. B o d yo f s c a p ua ,iiiuut..ii1ut,
2. G e n o i dc a v l t yo f s ca p u la lll:,rll1ll::,,rlr'
lii$lr,,,rlllt,:.
3. H e a do f h u m e r u s
4. Clavicle
5. L e s s e rt u b e r c l eo f h u m e r u s
6. B o d yo f h u m e r u s
7. S u p r a g l e n oti u
d b e r cleo f sca p u la
B. G r e a t e tru b e r c l eo f h u m e r u s
9. S p i n eo f s c a p u l a
 Radiographic
Anatomyof the Dog and Horse GF/7

Figure 5O-3- Mediolateral Radiograph of Canine

Humerus.
1 . H e a do f h u m e r u s
2 . R a d i o l u c e natr eacr e a te db y co n ce n tr a tioonf fa t,
ca u d alto shoul derj oi nt
capsule
3 . N e c ko f h u m e ru s Figure 5(H, Gaudocranial Radiograph of Canine
Humerus.
4 C a u d abl o r d e rof la te r ael p ico n d yle o f h u m e .u s 1. S pi neof scapul a
5 U a u d abl o r d e ro{ m e d ia lsg l6 9 n 6 yte o . h u r r e r ls 2. A cromi onof scapul a
o . u o n o y t eo t h u me r u s 3. V entral .{gl enoiangre
dr of scapura
7 . C r a n r abl o r d e ro f la r e r aet o .co n d yte
o +l- u r n e r u s 4. booy ol numerus
u . U r a n l abl o r d e ro f m e o ia le p ico .d yleo f h u m e r u s 5. Tuberol ecraniof ul na
y . p r o x t m apl l - y s i so f h u m e r u s
10 . C r a n i abl o r d e ro f le sse rtu b e r cleo f h u m e r u s 9 Y u9tulcoronoi dprocessof ul na
/. l vtedtateorcondylo{e humerus
11 . C r a n i abl o r d e ro f g r e a te rtu b e r cleo f h u m e r u s 8. C l avi cl e
1 2 . S u p r a g l e n oti u
d b e r cleo f sca o u la 9. Lessertubercl eof humerus
10. S houl der(humeralj ioi nt
11. Greatertubercl eof 'humerus
12. B odyof scapul a

i:--
678 RA DI O G RA PH AN
IC AT OMY

.,irr:;uri
:iiiuri::iil

Figure 50-5. Mediolateral Radiograph of Canine Elbow Joint.

1. A n c o n e apl r o c e s so f u ln a
2. T u b e ro l e c r a noi f u l n a
3. C a u d abl o r d e ro f l a te r ael p ico n d yle of humerus
4, C a u d abl o r d e ro f m ed ia le p ico n d yle of humerus
5, Lateralcoronoidprocessof ulna
6, P r o x i m arla d i o u l n ajor in t
7. M e d i a lc o r o n o i dp r oce sso f u ln a
8. H e a do f r a d i u s Figure 50-6- Graniocaudal Radiograph of Canine Elbow Joint.
9. C o n d y l eo f h u m e r u s 1. B odyof humerus
10. C r a n i abl o r d e ro f m e d ia e of humerus
l p ico n d yle 2. Tuberol ecraniof ul na
11. C r a n i abl o r d e ro f l a te r ael p co n d yleo f h u m e r u s 3. Medi aleoi condvl of e humerus
4. Medi alcoronoi dprocessof ul na
5, S uoeri moosed bodi esof radi usand ul na
6. H eadof radi us
7. E l bow(cubi talj )oi nt
8. Lateralepi condyl of e humerus
9. S upratrochl ear
foramenof humerus
10. A nconealprocessof ul na
 Radiographic
Anatomyof the Dog and Horse 67lt

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

Figure 5O-11. Dorsopalmar Radiograph of Canine Carpus.

Figuro 5O-1O. Mediolateral Radiograph of Canine Carpus. 1. B odyof radi us
2. D i stalphysi sof radi us
1. B o d yo f u l n a 3. D i stalepi physi of
s radi us
a hi^+ ^l , , l^^
^L. ,r^i^
pily rs ^{
ur uilr d 4. Medialstyloidprocessof radius
3. 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 5. Intermedi oradicarpal
al bone
4. Accessorycarpalbone 6. S esamoi dboneof abductorpol l i ci sl ongusmuscl e
5. U l n a rc a r p abl o n e 7. Firstcarpalbone
A N/ ai. ^^r ^^l h^nd F
8. Secondcarpalbone
7. M e t a c a r p abl o n e 1 a n d p r o xim ase l sa m o idb o n eo f d ig it1 L Metacarpalbone 1
L P r o x i m apl h a l a n xo f dig it 1 10. Metacarpal bone2
L Carpometacarpal joints 11, Metacarpal bone3
10. D i s t a b l o r d e ro f s e c o n dca r p a b
l one 12. lvletacarpal bone 4
'l 1. T h i r dc a r p a b
l one 13. Metacarpal bone5
12. M i d d l ec a r p ajlo i n t 14. Thi rdcarpalbone
13. I n t e r m e d i o r a d ci aalr pa b l one 15. Fourthcarpalbone
14. A n t e b r a c h i o c a r pj oalin t '16. U l narcarpalbone
15. D i s t a el piphysio s f r ad iu s 17. A ccessorycarpalbone
'16. Distalphysisof radius
18. A ntebrachi ocarpal j oi nt
' 17, B o d yo f r a d i u s
19. S tyl oi dprocessof ul na
20. D i stalphysi sof ul na
21. B odyof ul na
 682 RA DI O G RAP H AN
IC AT OMY

il$jui':,"

I
r ir
I

Figure 5O-12. Dorsopalmar Radiograph of Canin€ Manus'

1. B o d yo f r a d i u s
2. D i s t a p
l h y s i so f r a d iu s
3. M e d i a ls t y l o i dp r o c e sso f r a d iu s
4. In t e r m e d l o r a d icaal r pa bl one
5. S e s a m o i db o n eo f a b d u cto p r o llicislo n g u sm u scle Figure 50-13. PalmaromediaFDorsolateral Oblique Radiograph of
6. a onnnr l nr r nr l hnno C ani ne Manus.
7. F i r s tc a r p a b
l one 1. U l na
8. M e t a c a r p abl o n e 1 2. Accessorvcaroalbone
9. P r o x i m apl h a l a n xo f d ig it 1 3. Metacarpal bone 5
10. D i s t a lp h a l a n xo f d i g lt1 4. P roxi malsesamoi dbonesof di qi t5
11. N,4etacarpal bone 2 5. P roxi malphal anxof di gi t5
12. M e d i a lp r o x i m asl e s a m o idb o n eo f d ig it3 6. Mi ddl ephal anxof di gi t4
13. P r o x i m apl h a l a n xo f dig it2 7. U ngui cul ar
crestof di stalphal anxof di gi t4
14. M i d d l ep h a l a n xo f d ig it2 processof di stalphal anxof di gi t4
8. U ngui cul ar
15. D i s t a pl h a l a n xo f d i g it2 9. P roxi malphal anxof di gi t3
to. Metacarpalpad 10. P roxi malphal anxof dl gi t2
17. L a t e r apLr o x i m asl e s a m o idb o n eo f d ig it3 11. P roxi malphal anxof di gi t1
18. M e t a c a r p abl o n e3 '12. R adi us
19, M e t a c a r p abl o n e4
20. M e t a c a r p abl o n e5
21. Carpalpad
22. C a r p ab o n e3
23. C a r p abl o n e4
l-.Jlnar carpalbone
25. Anc oc c nr w. r r nr l h^na

26. Q + r , 1nid nr nnac < n{ r r ln a

27. B o d yo f u l n a
 Radiographic
Anatomyof the Dog and Horse 6a3

Figure 5O-14. Right-Left Lateral

Radiograph of Ganine pelvis.
1 . C a u d avl e r t e b r a1
2. Sacrum
3 , F i g h th i p { c o x a lj)oin t
4 . S u p e r i m p o s etdu be r ajsch ia d ica
5 . S u o e r i m p o s eodb tu r a to r + o r a m in a
6 . S u p e r i m p o s erda m io f jsch ia
7, Body of rjght femur
8. Body of left femur
9 . l l i o p u b i ce m i n e n ce
10 . H e a do f l e f t f e m u r
11. lntervertebral disc spacebetween L7
andS1
12. Vertebralcanalat levelof L7
13. Caudalextremity(fossa)of bodyof Lb

ti
t ')

i_^

Figure 5O-15. Ventrodolsal Radiograph of Canine pelvas.

1 Fecesi n descendi ng col on
2 Lett transverseprocessof L7
3 Wi ng of l eft i l i um
4. Sacrum
5. b:rd?r.of left_acetabulum superimposedon femorathead
6. P-oj::]
ureatertrochanterof Jeftfemur
7. Left obturatorforamen
8. Left tuberi schj adi curn superi mposed
on i emu.
9. booy ot tettl emur
'10. Left patella
11. R i ghtl ateralsesamoi dboneo{ gasrrocnemrus
muscl e
12. Caudalvertebra5
13. Lessertrochanterof ri ghtfemur
14. rovea capttisof .ight +emoralhead
tc. body ot fl ght i l i um
16. R i ghtsacroi l i ac j oi nt
17. lntervertebral disc spacebetween L7 and S1
18. )prnous processof L6
 684 RA DI O G RAP H AN
IC AT OMY

it
I'

Figure 50-16. Mediolateral Radiograph of Canine Femur.

1. P e l v i cs y m p h y s r s
2. lntertrochanteric crest
3. T u b e ri s c h i a d i c u m
4. L e s s e rt r o c h a n t eof
r fe m u r
5. B o d yo f f e m u r Figure 50-17. Craniocaudal Radiograph of Canine Femur.
6. M e d i a la n d l a t e r asl e sa m o idb o n e so f g a str o cn e m ium
s u scle
7. W a l lo f i n t e r c o n d yla for ssao f fe m u r 1. Greatertrochanter of femur
8. S u p e r i m p o s em d e d ia a l n d yle so f fe m u r
l n d la te r aco 2. N eckof femur
9. S e s a m o i db o n eo f po p lite u sm u scle 3. H eadof femur
10. F i b u l a 4. Lessertrochanterof femur
11. r b i a 5. P atel l a
12 , P a t e l l a 6. Medi alsesamoi dboneof qastrocnemi us muscl e
13 , H e a do f f e m u r 7. Medi alcondyl eof femur
14 . B o d yo f i l i u m 8. Lateralcondyl eof femur
9. Lateralsesamoi dboneof gastrocnemi us muscl e
10. B odyof femur
11. Lateralborderof tuberi schi adi cum
12. Trochanteric
fossa and intertrochanterlc
crest
 R adi ographiAcnatomyof the D og and Hor se 6g5

a lflllrriir,

Figure 5O-18. Mediolateral Radiograph of Canine Stifle Joint.

1. L a t e r as e s a m o i db on eo f g a str o cn e m r umsu scle
2. M e d i a ls e s a m o db on eo f g a str o cn e m ium s u scle Figure 50-19. Craniocaudal Radiograph of Ganine Stifle Joint.
3. S u p e r i m p o s em d e dia a
l n d /a te r aco
l n d yle so f fe m u r
4. S e s a m o i db o n eo f po pite u sm u scle 1. P atel l a
5. H e a do f f i b u l a 2. Intercondyl ar fossaof femur
6. B o d yo f f i b u l a 3. Medi alsesamoi dboneof gasrrocnemtus muscl e
7. B o d yo f t i b i a 4. Medi alcondyi eof femur
8. l l b r a lt u b e r o s i t y n
; co m p le te ly
Ju se dto b o d yo f ttb ia 5. Medi alcondyl eof ti bi a
9. C r a n i ailn t e r c o n d y laa r e ao f tib a 6. Medi ali ntercondyl ar tubercl eof ti bi a
10. I n f r a p a t e l l faart b o dy 7. Laterali ntercondyl ar tubercl eof ti bi a
11. T r o c h l e o af femur B . Ti bi altuberosi ty
12. P a t e l l a 9. C rani alborderof ti bi a
10. B odyof fi bul a
1'l. S esamoi dboneof popl i teusmuscl e
12. H eadof f i bul a
13. Lateralcondyl eof ti bi a
14. Lateralcondyl eof femur
15. Lateralsesamoi dboneof gasrrocnemrus muscl e
686 RA DI O G RAP H AN
IC AT OMY

Figure 50-21, Craniocaudal Radiograph of Canine Crus.

1. P atel l a
Figure 5O-2o. Mediolateral Radiograph of Canine Crus. 2. Medi alsesamoi dboneof gastrocnemi us muscl e
1 M e d i a ls e s a m o i db o n eo f g a str o cn e m iums u scle 3. Medi alw al l of i ntercondyl arfossaof femur
2 M e d i a lc o n d ye o f f e mu r 4. Medi alcondyl eof femur
? I .+ ar . l nnnnh, o n{ f om r r 5. Medi ali ntercondy ar tubercl eof ti bi a
4. S e s a m o i db o n eo f p o p lite u sm u scle 6. C ranraborderof tl bi a
5, H e a do f f i b u l a 7. B odyof ti bl a
6. B o d yo f f i b u l a 8. Medi a mal l eous of tl bi a
9. Tarsocrural j oi nt
7. T u b e rc a l c a n e i
8. B o d yo f t i b i a 10. Tal us
9. C r a n i abl o r d e ro f t i b l a 11. Lateralmal l eol usof fi bul a
10. T l b i atl u b e r o s i t y 12. B odyof fi bul a
' 11. T r o c h l e a
of femur 13. H eadof fl bul a
' 12, P a t e L l a 14. Lateralcondyl eof ti bi a
15. S ti fl e(genualj )oi nt
16. Lateralw al l of i ntercondyl arfossaof femur
17. Lateralsesamoi dboneof gastrocnemi us muscl e
18. B odyof femur
 Radiographic
Anatomyof the Dog and Horse 6g,

Figure 50-22. Mediolateral Radiograph of Canine Tarsus.

1. B o d yo f t i b i a
2. C a l c a n e u s
3. Tarsocrucal joint
4. Plantarprocessof centraltarsalbone
5. F o u r t ht a r s a lb o n e Figure 5O-23. Dorsoplantar Radiograph of Ganine
6. Metatarsalbone 'l Tarsus.
7. Superimposedmetatarsalbones2_b 1. B odyof fi buta
8. Superimposeddorsalbordersof secondand fourth 2. Tubercalcanei
tarsalbones 3. Lateralmal l eol us of fi bul a
9. Thirdtarsalbone
10. D o r s a bl o r d e ro f c e n tr ata 4. S ustentacul um tal i of cal caneus
l r sa ro o n e
11. H e a do f t a l u s 5. C al caneus
12. S u p e r i m p o s etda l u sa n d ca lca n e u s 6. Fourthtarsalbone
13. Trochleaof talus 7. B aseo+metatarsal bone5
14. B o d vo f f i b u l a 8. Metatarsalbone 4 (
9. l\4etatarsalbone 3
10. Metatarsal bone.2
11. Thi rdtarsalbone
12. S uperi mposed fi rst and secondtarsalbones
13. C entraltarsaibone
14. Tal us
15. Medi almal l eol us of ti bi a
16. Tarsocrural j oi nt
'17.C ommon
cal caneal tendonsuperi mposed on ti bi a
 688 RA DI O G RAP H AN
IC AT OMY

ii

Figure 50-25. Dorsoplantar Radiograph of Ganine Pes.

1. Tubercal canei
Figure 50-24. Dorsolateral-Plantaromedial Oblique Radiograph of 2. Medi almal l eol usof ti bi a
Ganine Tarsus. 3. S ustentacul um tal i of cal caneus
4. H eadof tal us
1. F i b u l a 5. C entraltarsalbone
2. T u b e rc a l c a n e i 6. S uperi mposed fi rst and secondtarsalbones
3. S u s t e n t a c u l u tm a l i su p e r im p o seodn ta lu s 7. Thi rdtarsalbone
4. C a l c a n e u s L Metatarsalbone 2
5. Fourthtarsalbone 9. Metatarsal bone3
6. Fifth metatarsalbone 10. Medi alproxi malsesamoi dboneof di gi t3
7. Fourthmetatarsalbone '11. Lateralproxi malsesamoi dbone
of di gi t3
8. S u p e r i m p o s etdh i r dan d se co n dm e ta ta r sablo n e s '12. Metatarsal pad
9. Secondmetatarsalbone 13. D i stalphal anxof di gi t4
10. F i r s tt a r s a lb o n es u p e r im p o seodn th ir dta r sa lb o n e 14. Mi ddl ephal anxof di gi t4
11. S u p e r i m p o s eddo r s om e d iaalsp e ctso f se co n da n d th ir dta r salbones 15. P roxi malphaLanx of di gi t4
12. C e n t r atla r s a lb o n e ',l 6.Metatarsal bone4
13. M e d i a lr i d g eo f t r o c h le ata li 17. Metatarsal bone5
18. Fourthtarsalbone
'19.C al caneus
 Radiographic
Anatomyof the Dog and Horse 689

Figure 5O-26. Mediolateral Radiograph of Canine Pes with Digits Spread.

1 . C o m m o nc a lca n e ate n ndon
2. Calcaneus
3 . T a p eu s e di n p o sitio n in g
4. Fourthtarsalbone r
5. Metatarsalbone 5
6 , P r o x i m asl e s a m o idb o n e so f d iq it5
7 . P r o x i m apl h ala n xo f d ig it5
8 . T a p eu s e d i n p o sitio n in g
9 . M i d d l ep h a l a n xo f d ig it5
1 0 . M e t a t a r s apl a d
1 1 . D i g i t apl a do f d ig it4
1 2 . U n g u i c u l aprr o ce sso f d ista lp h a la n xo f d ig it4
1 3 . P r o x i m ai ln t e r p h a la n g ejoain
l to f d ig it2
1 4 . T a r s o m e t a ta r sa l ts
io in
1 5 . D i s t a l n t e r t ar sa( ce
l n tr o d istajol)in t
1 6 . P r o x i m ailn t e r ta r sa( ta
l lo ca lca n e o ce n trioainl) t
1 7 . T a r s o c r u r iaorl nt
1 8 . B o d yo f t i b i a

Figure 5O-27. Left-Right Lateral Radiograph of Canine

Head.
1. C al vari a
2. Tympani cbul l ae
3. S tyl ohyoi bones
d
4. Soft palate
5. E ndotracheal tube
6. B asi hyoi bone
d
7. A ngul arprocesses of mandi bl es
8. B odi esof mandi bl es
9. Mandi bul ar canal s
10. R ootsof superi orcani neteeth
11. C oronoi dprocesses of mandi bl es
12. E thmoi dal conchae
13. Frontalsi nuses
690 RA DI O G RA PH AN
IC AT ON /Y

Figure 5O-29. Open-Mouth Ventrodorsal Radiograph of Canine

Nasal Gavity.
Figurc 50-28. Dorsoventral Radiograph of Ganine Head. 1. Left superi ori nci sor1
1. E n d o t r a c h etaul b e 2. Left superi ornci sor2
2. M e d i a ls u r f a c eo f e f t ma n d ib e 3. Left superi ornci sor3
? Tam nnr r l nr nnac c _ o-{t..,,g
nf ; ', 4. Left superi orcani netooth
o r a u cDo ce
4. C o r o n o i dp r o c e s so f l e ft m a n d ib le 5. Left superrorpremoar 1
5. Ai r w i t h i n e f t e x t e r n ala co u stc m e a tu s 6. N asalseotum
6. Le f t p a r a c o n d y l a p r o ce sso f o cclp itab o n e 7. Left ethmoi dalconchae
7. Le f t w i n g o f a t l a s 8. Temporaprocessof ri ghtzygomati cbone
8. Atl a n t o a x a j o r n t 9. S uperi mposed ri ghtdorsaland ri ghtventralnasalconchae
9. T h y r o i dc a r t i l a g oe f a r yn x 10. D entalcavttyof ri ghtsuperi orcani netooth
10. E n d o t r a c h etaul b e 11. R i ghtpal ati nefi ssure
11. E t h m o i d acl o n c h a e
12. R i g h ts u p e r o rp r e m o la4r
T 3. R g h t s u p e r l o p r r e m o la3r
T 4. R g h t s u p e r i o p r r e m o la 2r
15. R l g h ts u p e r l o p r r e m o la r1
16. R l g h ts u p e r i ocr a n i n eto o th
17. R l g h tl n f e r i o rc a n i n et o o th
 R adi ographiAcnatomyof the D og an d Hor se
G gl

Figure 5O-BI. Rostrodorsal_Caudodorsal Oblique Radiograph

C ani ne H ead. of
Figure 5O-3O. Intraoral Dorsoventral Radiograph
of Canine Nasal 1. Left l ateralfrontalsi nus
Cavity.
2. Zygomalicprocessof left fronratbone
1 C a r t i i a g r n o unsa s a se
l p tu m 3. Left zygomaticarch
2 Leftnostril 4. C oronoi dprocessof l eft mandi bl e
3. L e f t s u p e r i o irn c i s or3 5. C al vana
4. L e f t s u p e r i o cr a n i n eto o th 6. R i ghti ateralfrontalsi nus
5. D e n t a lc a v i t yo f I e f t su p e r io ca
r n in eto o th
6 L e f t s u p e r i op r r e m ola 1 r
7. L e f t s u p e r r opr r e m ola 2r
8. L e f t s u p e r i o p r r e m o la 3r
9 R i g h te t h m o i d acl o n ch a e
10. R i g h tm a x r l l a rrye c ess
11. F i g h ts u p e r i o p r r e mo la4r
12 N a s a ls e p t u m
13. S u p e r i m p o s erdi g h tdo r sa a l n d r ig h tve n tr a n
l a sa lco n ch a e
14. R i g h tp a l a t i n ef i s s u re
15. I n t e r i n c i s i vseu t u r e

:
692 RA DI O G RA P H A
ICN A T O MY

Figure 50-32. Rostroventral-Caudodorsal Oblique Radiograph of Ca-

ni ne Tympani c B ul l ae.
1. Left hal fof nasalcavi ty
2. Left suoeri orcheekteeth
3. Left zygomaticarch
4. C oronoi dorocessof l eft mandi bl e
5. Left petroustemporalbone
6. A ngul arprocessof l eft mandrbl e
7. Left tvmoani cbul l a
8. A tl anto-occi pi jtal
oi nt
9. B odyof eft mandi bl e
10. A xl s
11. N asooharvnx
12. R i ghtzygomati carch

Figure 5O-33. Left Caudal-Right Rostral Oblique Radio-

graph of Canine Tympanic Bullae and Left Temporoman-
dibula r J o i n t .
1. Le f t p a r a c o n d y l a p r o ce ss
2 R i g h ts t y l o h y o i d bone
3 A i r w i t h i nn a s o o h a r v n x
4. S o f t p a l a t el y i n go v e r en d o tr a ch e tu
al be
5. R i g h te p i h y o i db o n e
6. Le f t t y m p a n i cb u l l a
7. R i g h tt y m p a n i cb u l l a
8. Left retroarticular process
9. Le f t t e m p o r o m a n d r bu io la in
r t
10. Le f t t y m p a n o h y o icda r tila g e

Figure 5O-34. Left Dorsal-Right Ventral Oblique Radiograph of Left

Canine Tympanic Bulla and Temporomandibular Joint.
1. Tentori um cerebeli osseunr
2. E xternalocci pi taprotuberance
3. Occl oi tabone
4. R i ghttympani cbula supermposedon eft petroustemporalbone
5. Dorsa arch of atlas
6. D ensof axi s
7. Left paracondylar process
8. Junctl onof oropharynx and l aryngopharynx
9. Left tympani cbu l a
'0. Le{t te'rpororand oul arj oi nT
1 1. C oronord processof ri ghtmandl bl e
'12. R i ghtTygon-aTiarcl
c
13. Frontalsi nuses
 Radiographic
Anatomyof the Dog and Horse 693

rrr:trlr- .iiitl
' ::: .:l::.::'

iil],,,i]]!li:i;l

Figure 50.35. Left Ventral-Right

Dors a l O b l i q u e R a d i o g r a p h o f
Canine Right Superior Teeth.
Rostralroots of right superior
p r e m o l a4r
2. C a u d arl o o t o f r i g h tsu p e r io r
p r e m o l a 4r
3. R i g h ts u p e r i o mr o l a r1
4. R i g h ts u p e r i o mr o l a r2
5. R i g h ts u p e r i o pr r e m o la3r
6. R i g h ts u p e r i o pr r e m o la2r
7. R i g h ts u p e r i o pr r e m o la 1r
8. R i g h ts u p e r i o cr a n i neto o th
9. R i g h ts u p e r i o irn c i s o 3
r
10. R i g h ts u p e r i o irn c i s o r2

Figure 50-36. Left Dorsal-Right Ventral

Obl i que R adi ograph of C ani n e Inferi or
Teeth.
1. R i ghti nferi orcani netooth
2. R i ghti nferi orpremol ar1
3. R i ghti nferi orpremol ar2
4. R i ghti nferi orpremol ar3
5. R i ghti nferi orpremol ar4
6. Dentalcavityof right inferiormolar 1
7. Dentinof rostralroot of riqht inferiormolar 1
L P eri odontal l i gament{membrane ' )
9. Left inferiormolar3
10. Left mandi bui ar foramen
'l 1. Left mandi bul ar canal
12. Left i nferi ormol ar2
13. Caudalroot of left inferiormolar '1
14. C orti calboneformi ngw al l of al veol us{ l ami na
oura)
694 RA DI O G R AP H AN
IC AT OMY

Figure 5O-37. Ventrodorsal Intraoral Radiograph of Canine Inferior Teeth.

1. Left i nferi ori nci sor1
2. Maj ortubercl eof l eft i nferi ori nci sor2
3. Mi nortuberci eof l eft i nferi ori nci sor2
4. Left i nferi ori nci sor3
5. Left inferiorcaninetooth
6. Left i nferi orpremol ar1
7. Left i nferi orpremol ar2
8. Intermandi buljar oi nt(suture)
9. R i ghti nferi ormol ar1
'10, B i ghti nferi orpremol ar4
11. R i ghti nferi orpremol ar3
12. D entalcavi tyof ri ghti nferi orcani netooth

'llrl

:' ':: "'

"l:
:1'|rirr,l,

' ))).: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

Figure 5O-39. Ventrodorsal Radiograph of Canine Cervical Spine.

1 . L e ft p a r a co n d yla p r o ce sso f o ccp ita lb o n e
2 . A tla n to - o ccip itajo in
l t
3 . De n so f a xis
4 . S p in o u sp r o ce sso f a xis
5 . L e' r lr a n sve .se p .o ce sso I a r is
6 . L eft ca u d a al r ticu lapr r o ce sso f a xis
7 . L e ft p e d icleo f C3
8 . l n te r ve r te b r d
a isc
l sp a ceb e twe e nC4 a n d C b
9 . T u b e r ceo f le ft r ib 1
1 0 . S p n o u s p r o ce sso f T 1
1 1 . F ig h tsca p u la
' 1 2 . R g h t tr a n sve r sep r o ce sso f C6
1 3 . S p in o u sp r o ce sso f C4
14 . Rig h tth yr o h yo id b o n esu p e r im p o seodn crani alarti cul ar
foveaof atl as

u*'

Figurc 5O4O. Left-Right Lateral Radiograph of Canine Thoracic Spine.

1. Sp in e so f sca p u la e 6 Gasw rthi nstomach
2. Do r sa b o r d e ro f sca p u la 7. Intervertebral disc spacebetweenTg and T9
3. Sp in o u sp r o ce sso f T 5 8. Vertebralbody of T6
4. Sp in o u sp r o ce sso f T 1 0 ica u d a lly
in c l i ned) 9. Fi rstparrof ri bs
5. Sp in o u sp r o ce sso f T 11 ( a n ticlin a l
vertebra)

:-
696 RA DI O G RAP H AN
IC AT OMY

Figure 5041. Left-Right Lateral Radiograph of Canine Thoracolumbar Spine.

1. Cr a n iaal r ticu lapr r o ce sse o
s f T 12 6. Transverse processes of L4 supermposedon bodyof L3
2. LaminaeoI I12 7. C audalextreml ty(fossa)of L2
3. Acce sso r yp r o ce sse o s f T13 8 D orsaland ventralw a l s of vertebralcanal
4. Cr a n iaal r ticu lapr r o ce sse o
s f L2 9. Intervertebra di sc spacebetw eenT12 and T13
5. Ca u d aa r ticu lapr r o ce sse o s f L2 10. E l eventhpai rof ri bs

. ..11

lll$11irr
,ri r r ll,
'illrr'

Figure 5O42. Ventrodorsal Radiograph of Canine Thoracolumbar Spine.

'1. Body of T11
2. Headof l eft ri b 12
3. Tubercl eof l eft ri b 13
4. Gasw i thl ncol on
5. Intervertebral di scspacebetw eenL1 and L2
6. Left caudalartl cul arprocessof L2
7. Ri ghtcrani alarti cul arprocessof L3
8. Righttransverseprocessof L'1
9. Costalcarti l age of ri ghtri b 9
 Radiographic
Anatomyof the Dog and Horse 69z

::t:i]',::,
iill,.,l

Figurc 50-43. Left-Right Lateral Radiograph of Canine Lumbar Spine.

1. L a m in a eo f T 1 2 8. S pi nousprocessof L7
2. Accessoryprocessesof T13 I Cranialextremity{head)of L6
3. Ca u d aal r ticu lapr r o ce sse os f L1 10. Caudalextremity(fossa)of L5
4. Cr a n iaal r ticu lapr r o ce sse o
s f L3 11. Transverseprocessesof L4
5. Intervertebral foraminabetween L3 and L4 12. Thi rteenthpai rof ri bs
6. Synovial joints berween L4 and Lb 13. Intervertebral
di scspacebetw eenT12 and T13
7. Crestsof ilia

Figure 50-44. Ventrodorsal Radiograph of Canine Lumbar Spine.

1 . L e ft r ib 1 2
2 . Sp in o u sp r o ce sso f L 1
3. Left transverseprocessof L2
4. Intervertebral disc spacebetween L2 and L3
5. Left caudalarticularprocessof L3
6. Left cranialarticularprocessof L5
7 . Win g o f le ft iliu m
8 . L e ft wjn g o f sa cr u m
L M e ta llicfo r e ig nb o d ywith ind e sc endi ng
col on
1 0 . Rig h tsa cr o iliajoc in t
1 1 . Ga swith inco lo n
1 2 . Co sta ca e f r ig h tr ib jO
l r tila g o

Ej-
698 RA DI O G R A PH A
ICN A T O MY

t:tiltsu

,,lUr,'i.lll:

Figure 5O45, Left-Right Lateral Radiograph of Canine Lumbosacral Spine.

1 Aneoccnrrr nrncoecoc nf I I 6. Caudalvertebral
2. Cranialarticularprocessesof L5 7. Metal l i cforei gnbodi esw i thi ndescendi ng
col on
3. Ca u d aal r ticu lapr r o ce sse o
s f L5 8. Intervertebral di scspacebetw eenL7 and S 1
4. llia ccr e sts 9 Transverse processes of L6
5. Sp in o u sp r o ce sso f L 7 10. Intervertebral forami nabetw eenL5 and L6

Figure 5046. Ventrodorsal Radiograph of Canine Lumbosac/al Spine,

1. Left transverseprocessof L3
2. Soinousorocessof L4
3. Left crani alarti cul ar processof Lo
4. Left caudalarticularprocessof L6
5. j oi nt
Left sacrol l i ac
6. Metal l i cforei gnbodi esw rthi ndescendi ng
col on
7. C audalvertebra1
8. Intervertebral dl scspacebetw eenL7 and S 1
9. Intervertebral d sc spacebetween L3 and L4
 R adi ographiAcnatomyof the D og and Hor se 699

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

Figure 5O48. Ventrodorsal Radiograph of Canine Thorax.

1 C rani almedi asti num
2 C rani alpartof crani all obeof l eft l ung
3 Aortic arch
4 P ui monary trunk
5 C audalpartof crantall obeof l eft l ung
6 Left aurcl e of heart
7 Lel t ventri cl eof heart
8 C audall obeof l eft l ung
9 C audoventral medi asti num
10 A ccessoryl obeof ri ghtl ung
11. R i ghtcostodi aphragmati c
recess
12. C audall obeof rl ghtl ung
13. C auda obarbranchof ri ghtpu monaryvei n superi mposed
on cauo av enac av a
14. Mi ddl el obeof ri ghtl ung
15. R i ghtventrcl e of heart
16. R i ghtatri umof heart
17. R i ghtauri cl eof heart
18. C rani all obeof rj ghtl ung

==
7 OO RA DI O G RA P H AN
IC AT OMY

Figure 50-49. Left-Right Latctal Radiograph of Canine Abdomen.

1. Ca u d alo l b a rb r a n ch e so f p u lm o n a r vessel
y s 6. Fecesw i thi nrectum
2. Ga swith n b o d yo f sto m a ch su gastrc fol ds
; r r o u ndi ng 7. B ordersof uri narybl adder
3. Ventralborderof right kidney;contrastedby perlrenafat 8. Loopsof smal li ntesti ne(j ej unum)
4. l o r d e r so f le fr l' idney:crani aexrreri ty
Cr a ' r r aa.r ^ dca u d a o 9. Ventralextremityof spleen
o f le ft kid n e vsu p e r im p o seodn r ig h tki dney 10. Greatercurvatureof stomach
5 . Ga sa n dfe ce swith ind e sce n d inco g l on 11. Lrver
 Radiographic
Anatomyof the Dog and Horse 7Ol

Figure 50-SO. Ventrodorsal Radiograph of Canine Abdomen.

1 . Cu p u lao f d ia p h r agm
2. Left crus of diaphragm
3 . Ga swith insto m ach
4. Body of spleen
5. Cranialand caudalbordersof left krdney
6 . Ga swith ind e sce ndi ng col on
7. Prepucesuperimposedover L7 and sacrum
8 . Os p e n is
9 . Ga swith jnlo o po f j ej unum
1 0 . Ga swith ind e sce ndi ng duodenum
i 1 . Ca u d alo
l b a rb r a n chesof pul monary
vessel ssuperi mposed
on l j ver
7 O2 RA DI O G RAP H AN
IC AT OMY

I Radiographic anatomy of the horce

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,

Figurc 5(F52. Latoromedial Xeroradi_

ograph of Left Equine Carpus.
1. Ridgeson cranialsurfaceof raorus
2. Ridgeadjacentto lateralborderof
common digitalextensortendon
3. Caudalborderof radialtrochlea
4. Transversecrest of radius
5. Medialpart of carpalarticularsurface
6. I n t e r m e d i a tpea r to f ca r p aal r ticu la r
sufiace
7 . Lateralpart of carpalarticularsurface
8. Accessorycarpalbone
9. Dorsodistalborderof radialcarparoone
10 . D o r s o d r s t ablo r d e ro f in te r m e d ia te
ca r p a l
b o n e( C i )
11 , Proximalprocess(Ci)
12 . Dorsalsurfaceof ulnarcarpalbone
tJ. Arttculationof accessorycarpatDone
w i t h u l n a rc a r p abl on e ( Cu )
14. P a l m a b r o r d e ro f Cu
tc. Palmarborderof Ci
16 . Palmarborderof radialcarpalbone
17 . Dorsalborderof secondcarpalbone {C2)
18 . Dorsatboroerof rhird carpalbone (C3)
19 , D o r s a bl o r d e ro f f o u n h ca r p abl o n e ( C4 )
20. Palmarborderof C2
21. Palmarborderof C3
22. P a l m a br o r d e ro f C 4
23. Proximalborderof C2
24. Proximalborderof C3
25. Proximalborderof C4
26. Fourthmetacarpalbone
Secondmetacarpalbone
28. Metacarpaltuberosity
29. Antebrachiocarpal joint
30. M i d d l ec a r p ajlo i n t
Jt. Carpometacarpal joints
7 O4 RA DI O G RA PH A
ICN A T O MY

Figure 5O-53. Lateromedial Xeroradi-

ograph of Fl€xed Left Equine Carpus.
1 A ntebrachi ocarpal j oi nt
2 Mi ddl ecarpalj oi nt
3 C arpometacarpal j oi nts
4 Medialborderof medialpart of carpal
arti cul ar surface
5. Lateralborderof medialpart of carpal
arti cul ar surface
6. Medi alstyl oi dprocess
1. Shadowsfrom caudalaspectof
intermediatepart of radialtrochlea
8. I e to r a l ctr i l n i r l n r n n a cc
9. Transversecrest of radius
10. A..a cc^ ^ / ^ .r n e l
h^nd

11. Dorsoproximal borderof radialcarpal

bone (Cr)
12. Dorsoproximal borderof intermediate
carpalbone(C i )
13. D orsooroxi mal borderof ul n arc arpal
bone{C u)
14. Dorsodlstalborderof Cr (isolated)
t5. Dorsodistal borderof Ci
to. Dorsodistal borderof Cu
1 7 , P al marborderof C r
1 8 . P al marborderof C i
1 9 . P al marborderof C u
20. Dorsalborderof third carpalbone
Dorsalborderof fourth carpalbone
2 2 , Dorsalborderof secondcarpalbone
23. Thi rdmetacarpal bone
24. Thirdcarpometacarpal joint
2 5 , S econdcarpometacarpal j oint
26. Secondmetacarpalbone
2 7 . Fourthmetacarpalbone
28. Fourthcarpometacarpal loint
 Radiographic
Anatomyof the Dog and Horse 7O|5

Figure 5O-54. Dorsolateral-palmaro-

medial Oblique Xeroradiograph of Left
Eq u i n e C a r p u s .
1, R a d i o l u c e natr e aa t lin eo f fu sio n
between lateralstvJoidprocessand
radtus
2. Lateralstvloidorocess
3. M e dj a l p a r to f r a d iatr
l o ch le a
4, Lateralstvloidorocess
l o n e (Cr )
5. R a d i acl a r p a b
6. l n t e r m e d i a tcea r p alb o n e
7. U l n a rc a r p a bl one
8. Articulationsof accessorycarpalbone
with 2 and7
9. T h i r dc a r p a b
l one
10. S e c o n dc a r p a b l one
11. Fourthcarpalbone
12. Palmarpro1ection of C4
to, Fourthmetacarpal bone
14. S e c o n dm e t a c a r p ablo n e
13. Third metacarpal bone
to. Locationof metacarpal interosseous
lrgaments
17. D i s t a a
l s p e c to f d o rso m e d iablo r d e ro f Cr
(isolated)
70,6 RADIOGRAPHIC
ANATOMY

Figure 50-55. Dorsomedial-Palmarolateral Oblique

Xeroradiograph of Left Equine Carpus.
1. P roj ecti on of radi usfor attachmentof medi alcol l ateral
ilgament
2. Ridgethat forms lateralborderof groovefor common digrrar
extensortendon
3. Proximalborderof accessorvcaroalbone
4. Accessorvcaroalbone
5. Medi alstvl oi dprocessof radi us
6. LateralstvloidDrocess
7. R i dgeon caudalaspectof radi us
8, R i dgeat j uncti onof crani alsurfaceof radi usw i th carpal
arti cul arsurface
9. Dorsolateral borderof radialcaroalbone (Cr)
10. D orsol ateral bordersof ul narcarpalbone (C u)and
i ntermedi ate carpalbone (C i )
11. P roxi malsurfaceof C r
12. Proximalsurfaceof Ci
13. P roxi mal surfaceof C u
14. P al maromediborder al of C r
15. P al maromedioorder al of C i
16, P al maromediborder ar o. C _
17, S econdcaroalbone(C 2)
18. Thi rdcarpalbone(C 3)
19. Fourthcarpalbone (C 4)
20. Dorsolateral bordersof C3 and C4
21. A rti cul ati on
betw eenC 2 and secondmetacarpal bone(Mc 2)
22. Mc2
23. A rti cul ati on
betw eenC 3 and Mc3
24. Mc3
25. Inconstant arti cul ati on
betw eenC 3 and Mc2
26. Mc4
 Radiographic
Anatomyof the Dog and Horse 7O7

Figure Eo-86. Dorsoproximar-Dorsodistar obrique

Xeroradiograph of proximar Row of
Equine Garpal Bones,
1. Do r sasu
l r fa ceo +r a d iaca
l r p a bone
t 6. Dorsalsurfacesof distalcarpalbones
2. Do r sa su
l r fa ceo f in te r m e d ia te
carpalbone 7. Accessorycarpalbone
3. Do r sa su
l r fa ceo f u ln a rca r p aoone
r 8. Secondmetacarpalbone
4. Ra d iu s 9. Thirdmetacarpalbone
5. Carpalarticularsurfaceof radialtrochlea 10, Fourthmetacarpalbone

Figure 5(L57. Dorsoproximal-Dorsodis_

t al O b l i q u e X e r o r a d io g r a p h o f Dista l
How of Equine Garpal Bones.
1. D o r s a sl u r f a c eo f s e co n dca r p a Dol ne
2. D o r s a sl u r f a c eo f t h i r dca r p a o
t one
3. Dorsalsurfaceof fodrth carpatDone
4. Dorsalsurfaceof radialcarpalbone (Cr)
5. D o r s a sl u r f a c eo f i n te r m e d ia teca r p a b
l one
{ci)
6. D o r s a sl u r f a c eo f u l na rca r p aDo
t ne
7. Radius
8. Accessorycarpalbone
9. Interosseousspacebetween Cr and Ci
7 OA RA DI O G RAP H A
ICN A T O MY

,::r,ll F]

r;rll *tr:,ihti iiti;ur:

Figure 50-58. Lateromedial {LM} Xero-
radiograph of Left Equine Foredigit.
iiol,...iO,;,lrql
1. P roxi mali nterphal angeal j oi nt (P l J )
2. E xtensorprocessof di stalph al anx(P d)
3. j oi nt(Dl J )
D i stali nterphal angeal
4. Partof DIJ that extendsbetween Pd and
the di stalsesamoi di navi cuar ) bone
5. P roxi malextentof tubul arhor nformi ng
stratummedi umof hoofw al l
6. Juncti onof stratummedl uma nd l ami nar
hornof stratumi nternum
7. Transversepart of sole canalof Pd;
accommodates termi nalarchof di qi tal
vessel s
L Sole borderof Pd
9. P l anumcuneatumi sol esurfa c e)of P d
10. V ascul ar channel sextendi ngfrom s ol e
canalto sole borderof Pd
11. Flexorsurfaceof Pd
12, Fl exorsurfaceof navi cul ar bone
13. S uperi mposed medi aland l ateralpal mar
processesof Pd
14. R adi ol ucentareascreatedby fat w i thi n
synovialfolds
'15. B ordersof deep di gi talfl exortendon;
defi nedby fat w i thi nsynovi al fol dsof
di gi talsheath

Figure 5O-59. Dorsopalmar Xeroradio-

graph of Left Equine Foredigit.
1 P r o x i m ailn t e r p h a l a n g ejo ain
l t ( PlJ)
2 L a t e r adl i s t a ic o l l a t e r atul b e r cleo f p r o xim a l
p h a l a n x( P p )
3 M e d i a lp r o x i m ac o l l ate r atu l b e r cleo f
m i d d l ep h a l a n x( P m )
4 Extensorprocessof distalphalanx(Pd)
5 W a l l o f d e p r e s s i o inn Pm fo r a tta ch m e not l
m e d i a lc o l l a t e r al ilg a m e not f DIJ
6 D i s t a li n t e r p h a l a n g ejoain l t{ DlJ)
l Lateralextremityof navicularbone
8 Lateralpalmarprocessof Pd
9 F o r a m e ni n 8 t h a t a c co m m o d a tedso r sa l
b r a n c h e so f d i g i t avl esse ls
10 M e d i a ls o l ef o r a m e nof Pd ; r e ce ive sd ig ita l
v e s s e l sa s t h e y e n t e rso leca n a l
11 S o l eb o r d e ro f P d ;t y pica llyir r e g u la r
b e c a u s eo f n o t c h e sf o r va scu lach r a n n e ls
12. M e d i a lc o l l a t e r aglr o oveo f fr o g
1I a an+ r . l nr nnr r a nf { r nn

14. N o t c hi n s o l eb o r d e rasso cia tewith

d
v a s c u l acr h a n n eflr o m so leca n a lo f Pd
 Radiographic
Anatomyof the Dog and Horse ,Og

.;-;:i #i$a

Figure 5O-6O. Dorsal 65-Degree proximal-pal-

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 L e ft
Equine Foredigit.
1. P r o x i m ailn t e r p h a la n g ejoain l t{ p U)
2, M e d i a lp a l m a rp r o c e sso f d ista lp h a la n x( p d )
3. P r o x i m abl o r d e ro f n a vicu iaor o n e
4. V a s c u l afro r a m i n aa n d syn o viafo l ssa ea lo n gd ista l
borderof navicularbone
5. Air within centralgrooveof frog
6. Lateralextremityof navicularbone
7, Sole canalof Pd
8. D i s t a li n t e r p h a l a n gejoain
l t ( DlJ)
L Articulatjonof Pd with navicularbone; part of DIJ
10. Sole borderof Pd
11. C r e n am a r g i n i ss o l ea r is
12, Apex of frog
tJ. V a s c u l acrh a n n eflr o m so le ca n a lto so le b o r d e ro f
Pd
7 IO RA DI O G RAP H AN
IC AT OMY

rugiXlllqlA;X6
s* * l

Fi gure 5O-61. D orsoprox i mol ateral -

Palmarodistomedial Oblique Xeroradi-
ograph of Left Equine Foredigit.
1. D i stali nterphal angeal j oi n t(D l J )
of di stalphal a nx{ P d)w i th
2. A rti cul ati on
navi cul ar bone:oartof D IJ
3. Lateralextremityof navicularbone
4. Air within lateralcollateralgrooveof f rog
5. Lateralpalmarprocessof Pd
6. S ol ecanalof P d
7. E nd-onoersoecti ve of vasc ul ar c hannel
from sole canalto oarietalsurfaceof Pd
8. V ascul ar channelfrom solec analto s ol e
borderof Pd
L Lateralparietalgrooveof Pd;
accommodatesdorsalbranchesof diqital
vessels

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

Figure 5O-63. Lateromedial Xeroradiograph

of Left Equine Metacarpophatangeal Joint.
1. Distalend (head)of small metacarpal(Mc)
2. Dorsalpart of sagittalridgeof Mc3
3. Palmarpart of sagittalridgeof Mc3
4. Metacarpophalangeal .loint
5. Proximalsesamoidbones
6. Ergot
7. Straightsesamoidligament
8. Proximalinterphalangeal joint
7 I2 RA DI O G RA PH A
ICN A T O MY

Figurc 50-64. Lateromedial Xeroradio-

graph of Left E qui ne Meta c arpopha-
Iangeal Joint with Right Limb Lifted to In-
creaso Weight on Left Limb.
1. S uperfi ci aldi gi talfl exor(S D F)tendon
2. Interosseus
3. D eepdi gi talfl exor(D D F)tendon
4. Dorsoproximal aspectof proximalphalanx
(P o)
5. S ubtl etransverse ri dgeon hea dof the thi rd
metacarpalbone
6. Distincttransverseridgeat palmaredge of
arti cul arsurface
7. P al marannul arl i gamentof
metacarpophal angeal j oi nt
iriii:{tl:'i' 8. S D Ftendon
9. E rgot
10. Increased di stancebetw eenprox i mal
sesamoidbonesand Pp {see Fig. 50-63)
11. D D Ftendon
12. D i staldi gi talannul arl i gament
 Radiographic
Anatomyof the Dog and Horse 7l:l.

Figure 50-65. Lateromedial Xeroradio-

graph of Fle_xed Left Equine Metacarpo_
phalangeal Joint.
1. Sagittalridgeon head of third metacarpal
oone
2. Dorsoproximal aspectof proximalphalanx
3. Distalend of small metacarpatoone
4. Proximalsesamoidbones
t tr'^^+

6. De-epdigitalflexortendon
7 I4 RA DI O G RA PH A
ICN A T O MY

Figure 5O-66. Dorsoproximal-Palmarodistal

Oblique Xeroradiograph of Left Equine Metacar-
pophangeal Joint.
1. Lateralproxi malsesamoi dbone
2. D epressi oni n i nterosseus (abaxi alsurfac
) eof medi al
proximalsesamoidbone for attachmentof
interosseustendon
3. Palmaroproximal edge of proximalphalanx(Pp)
4. Depressionin third metacarpalbone (Mc3)for
attachmentof lateralcollateralligamentof McPJ
5. Sagittalridge on head of Mc3
6. Area of obliqueridgeon palmarsurfaceof Pp for
attachmentof medi alobl i quesesamoi dl i gament
7. Nutrientcanalthroughdorsalcortexof Pp
8. Lateraldistalcollateraltubercleof Pp
 Radiographic
Anatomyof the Dog and Horse 71|5

Figure 50-67. Dorsolateral-Palmaromedial

Oblique Xeroradiograph of Left Equine Met-
acarpophalangeal Joint.
1. Di s t a le n d o f f o u r t hm e ta ca r p ablo n e
2. Do r s o p r o x i m a sl p e c tof p r o xim apl h a la n x{ Pp )
3. De p r e s s i o inn i n t e r o sse usu s r fa ceo f m e d ia l
pr o x i m asl e s a m o i db o n efo r a tta ch m e not f
rn r e r o s s e uTse n o o n
4. Pa l m a r o a b a xbi aolr d e ro f la te r apl r o xim a l
s e s a m o i db o n e
5. Lateralproximalcollateraltubercleof Pp
6. Er g o t
7. Lateraldistalcollateraltubercleof Pp
8. Pr o x i m ai ln t e r p h a l a n g ejoain
l t
716 RA DI O G RA PH A
ICN A T O MY

lLir .,,f lN]llllli,, ,r

11i

L'lirisllral
iaill;ii18
ulllilii]],:
:llfr]rr.r11
illll'r1111!rl,

1lillll:,:lllf'l
llplilill
:iilllllll'.lil
Hl;lll
l1$Liili:
lljlirtl.illl

Figure 50-68. Dolsoplantar Xeroradiograph of Left Equine Tarsus.

1 . Me d ia lg r o o veo f tib ia lco che a 18. P roxi mali ntertarsal j o nt)
i tal ocal caneocentral
2 . L a te r agl r o o veo f tib ia lco ch le a 19. Tubercal canei
3 . Ob liq u er id g ese p a r a tin 1 g and2 20. C al caneoquartal j otnt
4 . P o n te d ca u d a e n d o f 3 21. P roxi mop antaraspectof centraltarsalbone(Tc)
5 . Ro u n d e dcr a na l e n d o f 3 22. Medi alaspectof Tc
6 . M e d ia lm a lle o lu s 23. Latera aspectof Tc
7 . C au d apl a r to f la te r aml a le o lu s 24. D i stali ntertarsal (centrodi stal l oi) nt
8 . C ra n iapl a r to f la te r am
l a le o lu s 25. Fusedfi rst and secondtarsalbones(T'landT2)
9 . Ra d io p a q ush e adow 26. A rti cul ati on
betw een25 and secondmetatarsabone
1 0 . T alu s 27. Medialaspectof rhird tarsalbone (T3)
11 . C aca n e u s 28. Lateralaspectof T3
' 2 . L aL e r aio' g eo f t' o ch le ata l 29. R adi opaque l i nesproducedby w al s of nonarti cul ar
1 3 . P r o xm a tu b e r cleo f ta lu s depressi on on T3
1 4 . D i sta tu b e r cleo f ta u s 30. Fourthtarsalbone
1 5 . V e d ia lr d g e o ' r r o ch le a[a lr 3'1. Tarsometatarsal j oi nts(al so,26)
1 6 . G r o o veb e twe e ^ 1 2 a n o 1 5 32. B aseof secondmetatarsal bone
17 [,4..1;a odno n{ c-6nt..' I Um ta i 33. B aseof fourthmetatarsal bone
"r
 R adi ographiAcnatomyof the D og and Hor se 717

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

Figure 5O-7O. Dorsolateral-Plantaromedial Oblique Xeroradiograph of Left Equine Tarsus.

1 . C ra n iaal sp e cto f m e d ia lm a lle o lu s 13. D orsomedi alaspectof thi rdtarsometatarsal j oi nt
2 . S h a d o wsp r o d u ce db y b o r d e r so f g r o o vein l ateralmal l eol us '14. Ridgeon dorsomedial
aspectof third tarsalbone (T3)
3 . D ista p l r o je ctio n
o f m e d ia lm a lle o lu s 15. NonarticularareabetweenTc and T3
4. Distalprojectionof lateralmalleolus 16. D orsalopeni ngof tarsalcanal
5 . C au d aal sp e cto f in te r m e d ia te r id g eo f tib ialcochl ea 17. P l antaropeni ngof tarsalcanal
6 . C 'a n iaal sp e cro f in r e r r n e d ia r e
r d g eo f r ib ,alcochl ea '18. Plantartuberosity
on fourth tarsalbone (T4)
7 . M ed ia lr id g eo ' tr o cl' le ata l 19. B aseof fourthmetatarsal bone(Mt4)
8 . L ate r arl id g eo f tr o ch le ata lr 20, ArticulationbetweenT4 and Mt4
9 . R a d io p a q uaer e ap r o d u ce db y d ista tu l b e r cl eof tal us 21. Interosseous spacebetw eenMt3 and Mt4
1 0 . S i nu sta r si 22. M12
1 1 . D or so m e d iaalsp e cto f p r o xim ain l te r ta r saljoi nt 23. C hestnut
' 1 2 . D or so m e d iaalsp e cto f d ista lin te r ta r sajol lnt 24. Tendonscrossi ngfl exorsurfaceof tarsus
 R adi ographiAcnatomyof the D og and H or se 719

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

Figure 50-72. Mediolateral Radiograph of Equine Shoulder Joint.

1. S upragl enoitubercl
d eof scapul a
2. C oracoi d processof scapul a
3. A i r i n trachea
4. C audalborderof gl enoi dcavi tyof scapul a
5. H eadof humerus
6. N eckof humerus
7. Deltoidtuberosityof humerus
8. S uperi mposed greater,l esser,and i ntermedi ate
tubercl esof humerus

llll.:i11rr,,.

:|,llillillli;r',
I
,

Figure 50-73- Mediolateral Radiograph of Equine E|bow Joint.

1. of humerus
C a u d abl o r d e ro f l a te r ael p ico n d yle
2. C a u d abl o r d e ro f m ed ia le p ico n d yle of humerus
3. T u b e ro l e c r a noi f u l na
4. L a t e r acl o r o n o i dp r oce sso f u ln a
5. P r o x i m arla d i o u l n arj o in t
6. R a d i atlu b e r o s i t y
7. Capitulum o f h u m e r aco n d yle
8. Trochlea o f h u m e r alco n d yle
9. A n c o n e apl r o c e s so f u ln a
 Radiographic
Anatomyof the Dog and Horse 721

Figure 50-74. Craniocaudal Radiograph of Equine Elbow Joint.

1 . l v l e d i ael p i c o n d y l o
ef h u m e r u s
2. O l e c r a n o on f u l n a
3. T r o c h l e ao f h u m e r aco
l n d yle
4. C a p i t u l u m
o f h u m e r aco l n d yle
5, Lateralcoronoidprocessof ulna
6. L a t e r abl o r d e ro f o l e cr a n o fo
n ssao f h u m e r u s

'l ,l
iiil',,lQ
r;lllli!lll

Fi gure 5O-75. Medi ol ateral R ad i ograph of

Equine Stifle Joint.
1 B aseof patel l a
2 Gl i di ngpartof arti cul ar
surfaceof patel i a
3. Locking(resting)part of articularsurfaceof patella
4. Lateralridge of femoraltrochlea
5. E xtensorfossaof femur
6. Fi bul a
7. llbial tuberosity
8. Intercondyi aremi nenceof ti bi a
L Apex of patella
10. Medi alri dgeof femoraltrochl ea
722 RA DI O G RA PH A
ICN A T O MY

lr..iiii6
:iauu

Figure 5O-76. Caudocranial Radiograph of Equine Stifle Joint.

1. B aseof D atel l a
2. Medi alepi condvl of
e femur
3. Medi alcondyl eof femur
4. Medi alcondyl eof ti bi a
5. Medi altuberce of i ntercondyl ar
emi nenceof ti bi a
6. Lateraltuberceof i ntercondyl ar
emi nenceof ti bi a
7. Fi bua
8. Lateralcondyl eof femur
9. Lateralepi condvl of
e femur
10. Lateralri dgeof femoraltrochl ea

Figure 50-77. Cranioproximal-Craniodistal Oblique Radiograph of

Equi n e S t i f l e J o i n t .
1. Cr a n i asl u r f a c eo f p a t ela
2. Fe m o r o p a t e l ljaori n t
3. La t e r arl i d g eo f f e m o r a trl o ch le a
4. Grooveof femoraltrochea
5. Ar t i c u l asr u r f a c eo f p a tela
6. M e d i a lr i d g eo f f e m o r a trl o ch le a
7. O s s e o u sp a r to f c a r t i l a g in o upsr o ce sso f p a te lla
 Radiographic
Anatomyof the Dog and Horse 72g

Figure 5O-78. Ventiodorsal Radiograph

of Foal Pelvis.
1. Wingof sacrum
2. Spinousprocessesof sacralvertebrae
3 . C a r t i l a g i n o uj usn ctio nb e twe e niliu ma n d
ischium
4 . P r o x i m apl h y s i s{ ep ip h yse a cal r tila g eo)f
femur
5 . Obturatorforamen
6. Cartilaginou j usn ctio nb e twe e ng r e a te r
t r o c h a n t ear n d f e m o r a lb o d y
7 . C a r t i l a g i n o upse i vicsym p h ysis
8 B o d yo f i s c h i u m
L G r e a t e trr o c h a n teor f fe m u r
10 . L e s s e rt r o c h a n t eor f fe m u r
11 . B o d yo f i l i u m
12 . C r a n i arla m u so f pu b isn e a r.l,o p u b ic
emrnence

Figure 50-79. Ventromedial-Dorsotatera! Oblique

R adi ograph of E qui ne H i p Joi nr ( 8-Month_dl d
Horse).
1. B odyof i l i um
2. C rani oventral borderof acetabul um
3. C rani odorsal borderof acetabul um
4. P roxj malphysi s(epi physeal carti l age)
o f femur
5. Shadowcreatedby caudaledge oi lessertrochanter
6. Radiolucentareacreatedby trochantericfossa of
femur
7. Cartilaginous junctionbetween greatertrochanterand
femoralbody
8. Greatertrochanter of femut caudalpar t
9. Tuberi schi adi cum
10. C arti l agi nor,s
oel vi csymphysi s
'11. B odvof
i schi um
12. C audoventral borderof aceTaoutum
13. Obturatorforamen
14. Radiolucent areacreatedbV acetabularfossa
'15. Radiolucent
areacreatedby grooveon ventralsurface
of pubisfor accessoryligamentof femoralhead
16. Radiolucent areacreatedby fovea capitisof femoral
head
17. C rani aledgeof acetabul ar notch
 724 RA DI O G RA PH A
ICN A T O MY

Figure 5O-8O. Left-Right Lateral Radio-

graph of Equine Atlas and Axis.
1. Occi pi talcondyl es
2. C rani alarti cul ar
foveaof atl as
3. Lateralvertebralforamenof atlasfor
passageof cervicalnerve 1
4. D ensof axi s
5. Ossi fi edl i gaments formi ngcran i albordersof
6; not ossi fi edi n younghorses
6. Lateralvertebralforaminaof axis for passage
of cervicalnerve2
7. S pi nousprocessof axi s
8. Intervertebral foraminabetweencervical
vertebrae2 and 3 for passageof cervical
nerve3
9. C rani alarti cul ar
processesof cerv i c al
vertebra3
10. C audalarti cul ar processes of cerv i c al
vertebra2 (axis)
11. Ventraltuberces of transverseprocessesof
cervicalvertebra3
12. Wi ngsof atl as

Figuro 50-81. Left-Right Lateral Radiograph

of Equine Cervical Vertebrae 4 and 5.
1. Caudalarticularprocessesof cervicalvertebra3
2. Spinousprocessof cervicalvertebra4
3. I n t e r v e r t e b rfaolr a m i nab e twe e nce r vica l
vertebrae4 and 5 for passageof cervicalnerve
5
4. C r a n i aal r t i c u l apr r o c esse o s f ce r vicave
l r te b r a5
5. La m i n a eo f c e r vc a l v e r te b r a5
6. Caudalarticularprocessesof cervicalvertebra5
L Vertebralforamenof cervicalvertebra5
8. I n t e r v e r t e b rdails cs p aceb e twe e nce r vica l
v e r t e b r a e5 a n d 6 l,
9. Dorsaltuberclesof transverseprocessesof
-
cervicalvertebra5
10. Caudalextremity{fossa)of cervicalvertebra4
11. C r a n i ael x t r e m i t y( h e ad o) f ce r vicavel r te b r a4
12. V e n t r atlu b e r c l e so f t r a n sve r sep r o ce sse osf
cervicalvertebra4
 Radiographic
Anatomyof the Dog and Horse 725

Figure 50-82. Left-Right Lateral Ra-

d i o g r a p h o f E q uin e Gu ttu r a l Po u ch
Region.
1 . C o n c h o f r o n t sain l u se s
2 . B a s i l apr a r to f o ccip itabl o n e
3. Rostralbordersof stylohyoidbones
d i v i d i n gc o m p ar tm e n ts o f g u ttu r a l
pouches
4 . C a u d abi o r d e rso f m a n d ib le s
5 . C a u d ael x t e n tof m e d ia lco m p a r tm e n ts
o f g u t t u r apl o uch e s
6 . C o r n i c u l a tper oce sse o s f a r yte n o id
c a r t i l a g eosf l a r yn x
7 . A r y e p i g l o t t ifco ld sco n n e ctin a g r yte n o id
a n d e p i g l o t t i cca r tila g eos f la r yn x
8 . E p i g l o t t i (sf o r me db y e p ig lo tticca r tila g e
of larynx)
9 . C a u d ael x t e n to f la te r aco l m p a r tm e n ts
o f g u t t u r apl o uch e s
1 0 . R o s t r abl o r d e rso f m a n d ib le s
1 1 . E m b e d d e dp a r to f su p e r io m r o la r s3
1 2 . E t h m o i d acl o n ch a e

::. lll'"liirll,,lll
IIIL
'l.. ..ii.l ir ..i
,ili'rlrr,illl,.iill!]l
:rdu:'rriiilll],.'lll1i
]llr,.rrlllil@)),,

Figure 50-83. Left-Right Lateral Radiograph of Equine Head.

1. W o l f t o oth ( su p e r iopr r e m oa r 1 ) 9. Temporomandi bulj oi arnt
2. S u p e r i opr r e m o la r s2 th r o u g h4 10. P etroustemporalbone
3. S u p e r i om r o la r s1 th r o u g h3 11. R ostralbordersof styl ohyoi d
bonesdi vi di ngcompartments
of gutturapouc
l hes
4. I n f r a o r b ita
cal n a ls 12. Caudalbordersof rami of mandibles
5. E t h m o id aco l n ch a e 13. Caudalsurfaceof epiglottis{formedby epiglotticcartilageof larynx)
6. C o n c h ofr o n ta l u se s
sin 14. D orsalsurfaceof soft pal ateoverl yi ngroot of tongue
7. Rostralbordersof coronoidprocessesof mandibles 15. l nferi orpremol ars
2 through4
8. Edgesof orbits

- ==-
-I

726 RA D IOGR AP H A
ICN A T O MY

Figure 50-84. Ventrodorsal Radiograph of Rostral Part of Equine

Head.
1. Left centrali nci sors(11)
2. Left cornerincisors(13)
3. R ostralpartof nasalseptumsuperi mposed on pal ati neproc es s esof
i nci si vebones
4. Left superi orcani netooth
5. B uccal(l ateraisurface
) of bodVof mandi bl e
6. Left inferiorpremolar2
7. Left superi orpremol ar2
8. Left superiorpremolar3
9. Left superiorpremolar4
'10. R i ghti nferi orpremol ar4
11. R i ghti nferi orpremol ar3
12. Li ngual(medi alsurface
) of bodyof mandi bl e
13. N asalseptumsuperi moosed on vomer
14. R i ght pal ati ne
fi ssure
15. R i ghti nferi orcani netooth
16. R i ghti ntermedi ate i nci sorsi l 2)

'l
':'l
l!]Ut,
tlliUu
'':11rr,ll ..** t$ur.il
:::t1n::
"a
, ll:'iili!lll

; _ ;;j liillllr,
''l
llrrllllll
''lirlr:

'l

Figure 5O-85. Left Ventral-Right

Dorsal Oblique Radiograph of Equine
Head.
1. Rootsof left superiorpremolar2
2 Rootsof left superiorpremolar3
3. Rootsof left superiorpremolar4
4. Rootsof left superiormolar 1
5. Maxillaryseptum between left rostral
a n d c a u d am l a xilla r sin
y ues
6. Rootsof left superiormolar2
7. Left infraorbitalcanal
8. Rootsof left superiormolar3
9 . R o o t so f r i g h tin fe r io rm o la r1
1 0 . R o o t so f r i g h tin fe r io rp r e m o la4r
1 1 . R o o t so f r i g h tin fe r io rp r e m o la3r
1 2 . R o o t so f r i g h tin fe r io rp r e m o la 2r
ffi Answers when the film was placed into the cassette,or when it was
processed.The mishandling resulted in a "crimp,', the pressure
of which resulted in exposure of the silver halide film crystals

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

10 1600 2. 1.54mm/psec (1540m/sec)

mA s , 3600' 3. The difference in an acoustic impedance between two tissues.
For higher differences in acousiic impedance between two
tissues, a higher percentage of the sound wave is reflected
lo and very little sound wave is transmitted. Inverselv, for lower
--:L-i^A.
mAs2 differencesin acoustic impedance between two tissues,a lower
percentageof sound wave is reflected and most of the sound
wave is transmitted.
^ 1 0=
mAs'z 4. Soft tissue-gas and soft tissue-bone interfaces.
0.44;
5. False.The difference in acoustic impedance between the body
wall and lung is very high so that nearly l00o/o of the sound
nrAs, : 22.7m4s wave is reflected at the lung-body wall interface.

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
of naturally occurring "magnetic" moments within the body in
the hydrogen atom. These atoms are placed in a strong magnetic
field and are pulsed with radiofrequency pulses. The relaxation
characteristicsof the hydrogen ions result in signal being given
off and image formation.
2. A 3. D 4 .D 5. AandC 6. 8 7. 4 8. E 9. A
Chapter 5: Introduction to Radiographic
Interpretation
l. When the thickness of the substancewith the lower effective
atomic number or physical density (or both) is much greater
than that of the other substance
2, Air (gas),fat, water (soft tissue),bone, and metal
3. Size,shape,number, Iocation, margination, and opacity
4. (B)
5. The small radiopacity cannot be a tracheal foreign body be-
cause its margin extends beyond the wall of the trachea' The
opacity cannot be a tracheal wall mass becausethe wall of the
trachea can be clearly seenthrough the mass.This opacity was
created by an engorged tick present on the side of the dog's
neck. It appearsso intenselyopaque becauseof the principle
describedin Figure 5-15. The gas superimposedon the dorsal
aspectof the opacity is gas in the cervical esophagus,a normal
finding. The small opacity slightly dorsocaudal to the larger
opacity is a film artifact createdby dirt in the cassette.
6. No, the dorsal (cranial) aspect of the subject should be facing
to the left, not the right.
7. (D) Distal to the antebrachiocarpal(tarsocrural) joint, the
front surface of the limb is called the dorsal surface;the back
surface of the forelimb is the palmar surface, and the back
surface of the hindlimb is the plantar surface.
8. (A) This artery would not be visible becauseit silhouetteswith
the myocardium. The other three structures are surrounded by
air-containing lung and will be clearly visible.
9. (A) Intrapericardial lipoma is least likely becausethe fat-
containing tumor would be visible as a mass of decreased
opacity in the cardiac silhouette, and separatefrom the heart.
The other conditions would result in a homogeneouslyopaque,
enlargedcardiacsilhouette.
10. Tiue. For easily accessibleparts, such as the canine elbow,
reversing the position of the x-ray tube and cassetteresults in
minimal differencesin the appearanceof the radiograph.
11. (1) Errors of searchingor scanning,(2) Errors of recognition,
(3) Decision making errors, and (4) Egocentricerrors
12. The cone of certainty is a conceptual way to place a degree of
confidence on a particular differential diagnostic consideration
when reviewing radiographic abnormalities. If one is low on
the cone of certainty, one is "uncertain" about a specific diag-
nosis as there are many possibilities and the radiographic
abnormality described is in fact a nonspecific change. If one is
high on the cone of certainty, the degree of certainty is based
usually on a number of radiographic abnormalities that in
combination provide a degree of confidence to the diagnosis
of a specific diseaseprocess.
13. Seetext.
14. A radiographic anatomic variant, a mirror, a window or a
picture (see text for details).
15. The changes associatedwith a pleural effusion include lung
lobe retraction away from the thoracic wall with soft-tissue
opacity separating the visceral and parietal pleural surfaces.
The pleural fluid is present between the lung lobes in the lobar
fissures. These fissures are present in the expected anatomic
location of a fissure. A lobar sign occurs when one lung lobe
is filled with soft-tissue opacity (cells and fluid) to the lobar
fissure. The fissure becomes apparent because the lung lobe
next to the infiltrated lobe is filled with air and forms a
contrasting opacity with the soft tissue. This should not be
confused with pleural fluid accumulation.
n Section ll:
il Axial Skeleton
Ghapter 6: lnterpretation Paradigms for the
Axial Skeleton-Small and Large Animal
l. This is the sixth cervical vertebra from a horse. C6 can be
identified becauseof the large transverseprocesses.
2. This radiograph is from the lumber region of a cat. Feline
lumbar vertebrae have a larger length-to-height ratio than do
those of the dog.
3.C 4.D
5. Spinousprocess,lamina, pedicle,transverseprocess,body, ar-
ticular process,and vertebral canal.
6. Conventionalradiography,magneticresonanceimaging, com-
puted tomography, and nuclear scintigraphy.
7. (1) Frontal sinus. (2) Tympanic bulla. (3) Coronoid process.
(a) Soft palate.(5) Nasalturbinates.
8. (1) Stylohyoid bone. (2) Epiglottis. (3) Guttural pouch. (4)
Ethmoid turbinates.(5) Coronoid process.
9. Five views are required: Iateral, VD/DV rostral caudal frontal
view, intraoral DV and open mouth VD.
10. False
Chapter 7: The Granial and Nasal
Cavities-Ganine and Feline
1. Cortical thinning, doming of the head, open fontanelles,and
a homogeneous brain appearance are radiographic signs of
hydrocephalus. Congenital hydrocephalus affects small-breed
dogs such as the Yorkshire terrier and the Chihuahua.
2. Renal and nutritional secondary hyperparathyroidism and pri-
mary hyperparathyroidism (tumor of the parathyroid gland)
cause overproduction of parathyroid hormone. Cortical thin-
ning, decreasedoverall bone opacity, and loss of the lamina
dura are seen on skull radiographs. In severecases,the teeth
are displaced and the mandible and maxilla are thickened
secondary to fibrous osteodystrophy.
3. The most useful radiographic views are the intraoral dorsoven-
tral or the open-mouth ventrodorsal view of the nasal cavity
and the rostrocaudal frontal sinus projection.
4. Nasal tumors are aggressivewith evidence of bony lysis, which
is seen on radiographs as loss of conchal detail. They are often
unilateral with ipsilateral frontal sinus involvement, represent-
ing either obstructive sinusitis or tumor extension.
5. Squamous cell carcinoma, fibrosarcoma, and malignant mela-
noma are oral tumors that can produce bony lysis of the
mandible or maxilla.
6. An intraoral ventrodorsal radiographic view of the mandible
would be helpful. Bony proliferation of the mandible in an
older cat could be consistent with scuamous cell carcinoma.

7. Aspergillosis.
8. There is an increasedsoft-tissue opacity to the right tyrnpanic
bulla consistent with otitis media.
9. Dogs have a draining tract under the eye. On radiograph, there
is a radiolucent halo surrounding one of the roots of the
maxillary fourth premolar.
f0, CMO typically affects terrier breeds, most notably the West
Highland White terrier. It has also been seen in Labrador
retrievers and in Doberman pinschers, and it is often seen in
young dogs under 1 year of age.
Ghapter 8: Equine Nasal Passages
and Sinuses
l lmmediately dorsal to the fourth premolar. This representsan
oblique laminar bony line as seen on the lateral and some
oblique radiographs.
2. The maxillary sinus surrounds the alveolar recessesof these
tooth roots. As the horse ages,the roots of the premolars and
molars impinge less and less on the maxillary sinuses.Thus
thesesinusesactuallybecomelarger as the animal ages.
3. Multiple views are required to rule out the possibility of de-
pressedfractures of the maxilla where there are fragments dis-
placed into the nasal passagesor a sinus. Such depressedfrag-
ments may not be visible on routine lateral and ventrodorsal
radiographs, and the physical deformity in the bone may be
masked by soft-tissue swelling.
4, Increased soft-tissue opacity to the caudal part of the nasal
cavity, and fluid lines in the frontal and caudal maxillary sinuses.
Note that there is no fluid in the rostral maxillary sinus.
5. The ventrodorsal view. Lesions of the septum are poorly seen at
best on any other view.
6. Although the mandible and teeth overlie the medial side of the
maxilla and may obscurelesionsin this area,it is the masseter
muscles that overlie the lateral part of the caudal maxillary
sinus. On straight ventrodorsal views of the maxilla, these mus-
cles impart a fluidlike opacity to the sinus, which could be
mistakenfor fluid in the sinus.
7. It is very unlikely that any lesion other than neoplasia would
result in fragmentation and displacement of a piece of cortical
bone or a tooth. Expansion and displacement of cortical bone
may occur with cystic lesions, but fragmentation and lysis of
that bone is not a featureof thesediseases.
8. The bony infraorbital canal. This structure becomesmore and
more visible as the animal agesowing to the progressivedown-
ward movement of the tooth roots.
Ghapter 9: The Vertebrae-Canine and Feline
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
vertebra to the sacrum.
2. True.
3. (1) Agenesis,(2) ftacture, (3) fusion failure of the odontoid
process,or (4) rupture of the stabilizing ligaments between Cl
and C2.
4, C4-5, C5-6, and C6-7 are the most frequently affected sites.
5. (1) Subluxation of the sacrum ventral to L7, (2) lumbosacral
stenosis,(3) collapseof the lumbosacral disc space,(4) nar-
rowing of the sacral vertebral canal or neural foramina, and
(5) protruding degenerativedisc.
AN SWER S 7 4
6. Discospondylitisis sepsis of the intervertebral disc space anc
adjacent ends of the adjoining vertebral bodies. Spond.r'lt-.i-o
deformans is a noninflammatory vertebral body remodeli:rg
that may vary in extent from the formation of small spurs tla
complete bridging of adjacent vertebrae.
7. Neoplasia, unlike discospondylitis, does not routinely result ir
end-plate lysis occurring simultaneously cranial and caudal to
an intervertebral disc.
8. Most primary vertebral neoplasms are osteosarcomasand re-
side within one vertebra. Most secondary vertebral neoplasms
are carcinomas and may reside in one or more vertebrae.
9. Discospondylitis at L4-5 and probably at L7-S1; probable
lumbosacral instability with spondylosis deformans.
10. The column of contrast medium from the epidurogram is
displaced dorsally by the protruding disc at L7-S1. There is
slight spondylosis ventral to 51. The dog has cauda equina
slmdrome from a herniating disc at L7-Sl, possibly due to
Iumbosacral instability.
Ghapter 1O: Ganine and Feline Intervertebral
Disc Disease, Myelography, and Spinal
Gord Disease
l.B 2.C 3.8
4. Multipoint centering, use of detail film-screen combinations.
and paying strict attention to patient positioning.
5. Narrowed intervertebral articular processjoint space,narrorted
intervertebral disc space,cloudy intervertebral foramen, small
int'ervertebral foramen. and presenceof extruded. mineralized
disc material within the vert;bral canal.
6.B 7.F
8. Intradural-extramedullary.
9. Slight epidural leakageof contrast medium around the needle.
10. Extradural.
Ghapter 1 1: The Equine Vertebral Column
l. Metrizamide;2. D;3. Tiue; 4. A; 5. D; 6. A; 7. C; 8. B
9. The contrast myelogram is normal. The narrowing of the
ventral aspect of the contrast medium column on this flexion
study is a normal finding. Notice that the dorsal aspect of the
contrast medium column remains normally wide.
10. In this extended view there is compression of the ventral and
dorsal aspectsof the contrast medium column at C5-C6 and
C6-C7 . The vertebra labeled with the arrow is the sixth cenical
vertebra and is identifiable in the vast majority of horses
owing to the large lateral process with the separate center of
ossification at the caudal aspect.
Section lll:
II
I Appendicular
I Skeleton-Ganine and Feline
Ghapter 12: Interpretation Paradigms for the
Appendicular Skeleton-Ganine and Feline
l.B 2.D 3.D 4.D
5. Endochondral ossification results in bone developm.trl l6ilgrrr-
ing a cartilaginous model. This is true for long and sho:-
bones. Normal physeal development occurs via endochoncri
7IO ANSWERS
ossification. Intramembranous ossification occurs in flat bones
in which bone mesenchymedevelops from a mesenchymalpre-
cursor tissue without a cartilaee model.
6.D 7 .C 8.D 9.E
Chapter 13: Diseases of the lmmature
Skeleton
l. True. The subchondral bone defect seenradiographically is due
to a failure of cartilage mineralization during endochondral
ossification.Surroundingbone sclerosisis a secondaryresponse
to the primary disease.
2. False. Osteochondrosis lesions are more often bilateral, al-
though lesions may not be bilaterally symmetric and clinical
signs may be unilateral. In addition, dogs with osteochondrosis
at one anatomic site often have additional lesions at other sites.
3, The anconeusshould fuse to the ulna by 4 to 5 months of age,
so an ununited anconeus is diagnosed after 150 days of age.
4. False.A medial coronoid fragment is often not radiographically
visible either becauseit is poorly mineralized or superimposed
on the radius or degenerativenew bone.
5. Hypertrophic osteodystrophy(HOD) is the most likely diagno-
sis. The radiographic changesand clinical signs describedare
characteristic of HOD. Hematogenous osteomyelitis could also
be considered.
6, (A) diaphysis,near nutrient foramina. Medullary sclerosiswith
or without continuous periosteal new bone formation is a
classicchange associatedwith this disease.
7, Many of the osteochondrodysplasiaslead to disproportionate
dwarfism. In some forms, only the long bones appear to be
affected, whereas in others, the axial skeleton is also involved.
8. There is increased medullary opacity in the distal humeral
diaphysis (compare the humeral medullary opacity with the
relatively lucent proximal radial diaphysis). Radial-ulnar joint
incongruity is present with a small "stairstep" at the articular
junction of the radius and ulna. Subtle enthesophyte bone
production is presenton the anconealprocess.The areaof the
medial coronoid process of the ulna is not well defined' Mild
bone sclerosis is present along the subtrochlear bone and
adjacent to the lateral coronoid process.Changesare consistent
with panosteitis in the distal humerus, elbow dysplasia (joint
incongruity), minor degenerative joint disease,and possible
fragmented medial coronoid process.Additional views of the
medial coronoid process are recommended. The panosteitis is
probably responsible for a major portion of the lameness,but
the joint incongruity, minor arthritis, and possible fragmented
coronoid processcould causethe lamenessto persist after the
panosteitis has resolved.
9. There is cranial and medial bowing of the radius. There is a
retained cartilaginous core in the distal ulna. The radial and
ulnar physesappear normal and open. There is mild humeral-
ulnar joint subluxation seen on the craniocaudal view. The
caudal radial cortex is thickened, probably secondaryto abnor-
mal weight bearing. The angular limb deformity is probably
secondary to growth interruption of the distal ulnar physis
by the retained cartilaginous core. Ulnar ostectomy is the
recommended surgical procedure.
10. There is subchondral bone flattening and lucency in the medial
humeral condyle. Bone sclerosisis seenadjacent to the lucency.
Minor enthesophyteformation is present on the medial aspect
of the medial condyle. Radiographic diagnosisis osteochondro-
sis of the medial humeral condyle with mild degenerative
joint disease.
Ghapter 14: Fracture Healing
and Complications
r.c 2. E 3.C 4.C s.D 6.D 7.C 8. B 9.D l0.A
Chapter 15: Bone Tumors Versus
Bone Infections
l.A 2. C 3.A 4.B 5.8 6.E 7.D 8 . L e s s 9 .A l 0 .D
Ghapter 16: Radioglaphac Signs of Joint
Disease
l. The tendons in which each of the four sesamoidbones of the
stifle joint are located include the (1) tendon of insertion of
m. quadricepsfemoris (patella), (2 and 3) medial and lateral
headsof m. gastrocnemius (fabellae),and (4) tendon of origin
of m. popliteus(popliteal sesamoid).
2. Radiographic signs of joint diseaseinclude (1) synovial effu-
sion, (2) altered subchondral bone opaciry (3) osteophyte/
enthesophyte proliferation, (4) soft-tissue mineralization, (5)
intra-articular calcification, (6) bone cyst formation, (7) sub-
chondral bone erosion, (8) joint malformation, (9) joint dis-
placement,and (10) alteredjoint spacethickness.
3. (c) synovial effusion.
4. Types of stress that can be applied to a joint during stress
radiography include (1) traction, (2) rotation, (3) wedge, (a)
compression,and (5) shear.
5. The primary joint neoplasm is synovial sarcoma. Other neo-
plasms that can appear radiographically similar to it include
(l) fibrosarcoma,(2) rhabdomyosarcoma,(3) fibromyxosar-
coma, (4) malignant fibrous histiocl'toma, (5) liposarcoma,
and (6) undifferentiated sarcoma.
6. For shoulder arthrography ofa juvenile Labrador retriever with
suspectedOCD of the humeral head,use 2 to 4 mL of a sterile,
aqueouscontrast medium at a concentrationof 100 mgl/ml.
7. Intra-articular calcified bodies occur in the canine elbow be-
causeof (1) OCD of the medial humeral condyle,(2) ununited
anconealprocessof the ulna, (3) fragmentedmedial coronoid
process of the ulna, and (4) avulsion fractures involving the
joint.
8. There is a triangular radiolucent lesion in the distal radius that
extends to the radiocarpal joint. Using stressradiography (Fig.
16-35), an articular fracture with a large bone fragment dis-
placed distally becomes apparent.
9. Slight unilateral joint laxity (right) is evident in Figure 16-33.
\Mhen a distraction (PennHip) view (Fig. 16-36) is taken to
further evaluate the coxofemoral ioints, it becomes evident
that joint laxity was not disclosed by the extended view Diag-
nosis: Hip dysplasia.
10. Florid new bone formation is present around the bicioital
tendon (a) and the caudaljoint pouch (&), indicating synovial
calcification(Fig. 16-37). Increasedosteolucencyis presentin
the humeral head (c). Interpretation: Septic arthritis.
I Section lV:
I Appendicular
I Skeleton-Equine
Ghapter 17: Interpretation Paradigms
for the Appendicular Skeleton-Equine
r.A 2. F 3.A 4.4 5.C 6.8 7.C 8.C 9.B 10.A
Ghapter 18: The Stifle
l. A 2. C 3. D 4. D 5. E 6. False 7. Tiue 8. False
Chapter 16 answers courtesy of Alice Springs Veterinary Hospital, Alice Springs,
Australia.
 ANSWERS 73I

Figure 16-35 Figure 16-37

Ghapter 19: The Tarsus
l. D 2 .E 3. A 4. Fals e 5. B
Ghapter 2O: The Equine GarPus
l. Five views.Theseinclude the dorsopalmar,lateromedial,flexed
lateromedial,dorsal 60-degreelateral-palmaromedialoblique'
and dorsal 60-degreemedial-palmarolateraloblique' Dorso-
proximal-dorsodistaloblique views are specialviews.
2. (1) Intracapsularsoft-tissueswelling and (2) the radiographic
findings seenin the five standardprojectionsdo not correlate
with the clinical signs or joint capsuledistention
3. Distention of the middle carpal joint indicatesthe need for a
distal row examination, and distention of the antebrachiocarpal
indicates a need for examination of the distal radius.
4. (B)
5. Chip, slab, and sagittal fractures.
6. Radial carpal bone.
7, A carpal radiographic examination should be done on a foal
with angular limb deformity for the following reasons: (1) to
determine the origin of the deviation (i.e., growth plate of
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;
and (3) to provide a basis for evaluating treatment success.
8. Treatment may correct growth imbalances associatedwith the
carpus as the foal develops. A growth imbalance resulting in
bone and joint changesat the metacarpophalangealjoint can-
not be corrected if the physes have closed or have limited
growth potential remaining. Radiographic closure of the physis
of the distal radius occurs at approximately 30 months, and
that of the distal third metacarpus and proximal aspect of the
proximal phalanx occurs at approximately 6 to 8 months.
9. A more complete radiographic examination consisting of five
routine views and a dorsoproximal-dorsodistal oblique view is
needed to determine (1) changesin the slab fracture (i.e.,
displacementor comminution), (2) presenceof additional frac-
tures, (3) size and thickness ofthe slab on the dorsoproximal-
dorsodistal view, (4) the degree to which the fracture reduces
on the flexed lateromedial view or (5) evidence of secondary
joint diseasein the carpus.
10. The intermediate carpal bone is more proximal than the radial
carpal bone. Therefore, the dorsoproximal intermediate and
the dorsodistal radial carpal bones are seen without being
overshadowed.
Ghapter 21: The Metacarpus and Metatarsus
1. False 2. True 3. False 4, Tiue 5, True 6. Tiue
7. Distal condyle (sagittal),dorsal-distalcortex (saucer),and pal-
mar/plantar proximal cortex
8. Mach bands.
9. The nutrient foramen
10. The suspensoryligament (branches).
11. Superficial digital flexor tendon; deep digital flexor tendon;
accessory("check") ligament of the deep digital flexor tendon;
and suspensoryligament
12, Clarity of image, adequate penetration, and probe design.
13. The following preparation is necessary:a thorough under-
standing of regional anatomy; knowledge of published varia-
tions in sonographic appearanceof tendons and ligaments;
training and experiencein the use of ultrasound machinesand
probes; training in the interpretation of equine limb sono-
grams; and a thorough physical examination of the limb.
Chapter 22: The Metacarpophalangeal
(Metatarsophalangeal) Articulation
1.D 2.C
3. There is flattening and excavation of subchondral bone at the
palmar articular radius of MC III with sclerosisand compres-
sion of trabecularbone deep to the areaof flattening.Findings
are consistent with osteochondrosis. Additional radiographic
examination should include dorsopalmar and oblique projec-
tions. Radiography of the contralateral limb is advised.
4.8 s.A
6. There is extensivesoft-tissue swelling around the joint; the axis
of the MCP joint is straight and the cartilage space of the
entire joint is wide. There is lysis and destruction of subchon-
dral bone of distal MC III and the epiphysis of the proximal
phalarx. Linear bony opacitieswith sharp, distinct margins are
present at the joint surfaces. Findings are an indication of
advancedseptic arthritis with multiple sequestra.
7.C 8,C
9. There is a smooth osseousfragment of bone along the plantar
margin of the proximal phalanx, medial to the sagittal groove,
and there has been remodeling and separation of bone of the
medial plantar eminence. These findings are reported as frac-
tures or osteochondrosisand siven the classification of tvoe I
and type II fragments.
r0. B
Ghapter 23: The Phalanges
l. (A) The high-ioad/1ow-motion character of the proximal inter-
phalangealjoint makes it prone to degenerativijoint disease,
in which subchondral bone resorption is a common feature
identified by radiography. Selection (B), osteochondrosis,is
incorrect becausealthough one form of equine osteochondrosis
is typified by subchondral bone lucency in the distal end of
the proximal phalanx, it is uncommon to have more than one
subchondral defect. |oint space narrowing and osteophytes,
however, can be sequelaeof osteochondrosis.Selection (C),
acute, active septic osteoarthritis, is incorrect becausethe initial
radiographic appearanceof this condition is most often unre-
markable except for soft-tissue swelling associatedwith joint
capsule distention. Untreated, septic arthritis progressesto the
appearanceofjoint spacewidening owing to cartilageloss and
subchondral bone lysis. As is illustrated in Figure 23-12F,
chronic, low-grade septic osteoarthritis could appear as de-
scribed for this patient.
2. A dorsopalmarview (using a horizontal beam) or a dorsal 45-
degreeproximal-palmarodistal oblique view would be the best.
Calcification in the collateral cartilaees would be easilv seen
and would appear within the soft tisi-res medial and lateral to
the distal interphalangeal joint. If the calcification was wirh-
in the deep digital flexor tendon, it would be superimposed by
the bone opacity of the middle and distal phalangesand would
not be readily visible on the dorsopalmar view.
3. Common radiographic signs seen with chronic laminitis in-
clude palmar rotation or deviation of the distal phalanx; gas
dissectionbetweenthe laminae;an increasednumber of circu-
lar vascular channel lucencies in the midbody of the distal
phalanx on the dorsal 65-degree proximal-palmarodistal
oblique view; fractures along the solar margin of the distal
phalanx, especially at the toe region; a long hoof wall at
the toe; and a domed dorsal margin of the distal phalanx
(Iateral view).
4. The opacity of the periosteal reaction should be carefully com-
pared with the opacity of the underlying cortex. If similar, the
opacity (along with the smooth surface margin) would suggest
that this reaction is considerably older than 10 days and is
unlikely to be associatedwith the current cause of lameness.
Another consideration is whether any soft-tissue attachments
occur in the area of the periosteal reaction. If yes,the periosteal
reaction may indicate a previous strain injury, with a recent
reinjury to the tendon, ligament, or joint capsulesuperimposed
on the older osseousresponse.
5. The linear radiolucency may be a fracture line, or it may be a
vascular channel in the distal phalanx. The most useful addi-
tional radiographic projection would be a dorsal 65-degree,
proximal 45-degreelateral-palmarodistomedial oblique view. If
the lucency is a fracture, the primary beam will pass straight
through the fracture plane on the oblique view and enhance
its visualization. If it is a fracture that extends into the distal
interphalangeal joint, displacement of the subchondral bone
margin will be visible on the oblique view. A hoof tester should
also be used to determine if there is focal sensitivitv to oressure
in the suspect area.

6. The most important preparations involve removing any extra-
neous material from the patient's foot, including bandages,
shoes,pads, and medications. The sulci of the frog should be
thoroughly cleaned with a narrow-bladed hoof pick to ensure
that no small bits of gravel remain in the deepest crevices of
the frog. The sulci should then be packed with a material that
has the same radiopacity as soft tissue.
7. Abnormal radiographic signs on the lateral view include mod-
erate palmar rotation of the distal phalanx, gas dissection
between the hoof wall and underlying lamina, and a faint bone
opacity at the tip of the toe of the distal phalanx. The dorsal
65-degreeproximal-palmarodistaloblique view exposedto
show the entire distal phalanx shows no changesin the body
and the distal interphalangeal joint. On the dorsal 65-degree
proximal-palmarodistal oblique exposedto optimize evaluation
of the toe, there is a fracture along the solar margin of the
distal phalanx from the toe through the lateral quarter. Radio-
graphic diagnosis was chronic laminitis with type VI distal
phalanx fractures.
8. Three variable-length radiolucent lines are seen within the
middle phalanx on the lateral view; two enter the middle
region of the proximal interphalangealjoint, resulting in mild
distraction at the joint surface. The longer line involves the
distal interphalangealjoint at the palmar condylar surfacejust
dorsal to the distal border of the navicular bone, without
significant distraction. The fracture is not visible on the dorso-
palmar view. A slight step effect is evident, however, in the
lateral half of the proximal subchondral bone of the middle
phalanx, which indicates the fracture location at this articula-
tion. An additional finding is a fracture through the lateral
aspect of the navicular bone seen as an oblique linear lucency
through the lateral part of the bone on the dorsopalmar view.
This fracture accounts for the unusual shape of the proximal
margin of the navicularbone in the lateral view, as the lateral
fragment is distracted proximally. Radiographic diagnosis was
biarticular middle phalanx fracture with minimal distraction.
Navicular bone fracture. Comment: Fracture visibility on any
one view dependson the completenessof the fracture and the
distracting forces on the fragments.When the fragments are
minimally displaced,the fracture plane may be optimally visu-
alized on only one view. In this horse, oblique views may have
increased the visibility of the fracture plane. Follow-up: The
distal limb was placed in a cast. Three months later, the middle
phalanx fracture was radiographically healed. Osteoarthritis of
the proimal interphalangealjoint (but not the distal interpha-
langeal joint) was evident radiographically. There was no osse-
ous union of the navicular fracture. At that time, the horse
was not lame when allowed free movement in the pasture.
9. The area of sole d6bridement is seenat the toe. A focal area
of osteolysisin the toe of the distal phalanx, just medial to the
midsagittalplane, is seenin all views. On the dorsal 65-degree
proximal-palmarodistal oblique view, the osteolysisis seen as
a larger defect in the bone, and a bone opacity is separated
from the toe. The line drawing of the dorsal 65-degreeproxi-
mal-palmarodistal oblique view (Fig. 23-37) can be correlated
with the radiograph. Radiographic diagnosis was septic pedal
osteitis with bone fragment consistentwith sequestrum forma-
tion. Tieatment was deeper curettage of the abscessand re-
moval of the bone fragment. Cornments:Debridement of the
sole can create a defect that is not often amenableto successful
packing with soft-tissue equivalent material, especially in the
field. The artifacts created by the nonuniformity of the sole
make interpretation of the toe region of the dl$tal phalanx
difficult on the dorsal 65-degree proximal-palnrarodistal
oblique view. When this situation is encountered, the dorso-
palmar. view using a horizontally directed beam shpuld also
De useo.
ANSWERS 73
RH
Sequestrum
Figure 23-37
10. Osseousabnormalitiesinclude malalignment of the proximal
interphalangealjoint (flexural deformity) as seen on the lateral
view and extensive periosteal proliferation around the distal
third of the proximal phalanx. The density of the bony prolifer-
ation indicates that the periosteal stimulus is chronic, whereas
the irregular surface margin suggestsan active process. Soft-
tissue thickening is also identifiable, especiallyalong the lateral
and medial sides of the proximal interphalangealjoint. Radio-
graphic diagnosis was chronic flexural deformity of the proxi-
mal interphalangeal joint with severesecondary osteoarthritis.
Comments: The flexural deformity could not be reduced by'
manipulation of the joint or by having the foal place full weight
on the leg. Surgicalarthrodesiswas recommendedbecauseof
the extent of the deformity and the progression of secondarl'
joint disease.
Ghapter 24= The Navicular Bone
l. C 2. B 3. D 4. A, C, and D 5. True 6. E 7. False
8. Constant fragment motion, poor osteoprogenitor cell availabil-
ity, and influx of synovial fluid hampers healing.
9. A 10. B, C, and E
il Section M
I Neck and Thorax-Gompanion
X Animals
Qhapler 25: Interpretation Paradigms for the
Small Animal Thorax
l. (1) Two radiographsshould be obtained at orthogonal views,
including lateral and VD or DV views; (2) radiographs should
be obtained on inspiration; and (3) a long-scalecontrast or
latitude radiograph should be made using a high-kVp and
low-mAs technique.
2. Inspiration: The diaphragm moves caudally. There is an in-
creased distance between the cardiac silhouette and the dia-
phragm. The lung lobes appear "Iarger" and more "inflated"
(e.g., on the lateral view, the lungs extend to the sternum .
The lungs appear more "radiolucent"; however, pulmonan-
markings are still seen.Expiration: The diaphragm and cardiac
silhouette are in close apposition. The lung lobes seen:
"smaller" and less "inflated." The lungs appear more radilr-
paque (increased soft-tissue opacity). This may cause an arLi-
factual appearanceof an unstructured interstitial panern.
734 ANSWERS
3. The lesion will be inconspicuous in the right lateral radiograph
becausethe dependent lung lobes will collapse and there will
then be lessintrapulmonary air to contrastwith the lesion.
4. There are four basic areas that need to be reviewed. These
include the extrathoracic structures, pleural space,pulmonary
parenchyma, and mediastinum.
5. In the geriatric thorax of a dog, there would be degenerative
changesof the vertebral column, degenerativechanges of the
scapulohumeral joint, degenerative changes of the sternebrae
and costal cartilages,presenceof pulmonary osteomas,in-
creasedunstructured interstitial lung opacity, and pleural
thickening (particularly between the right middle and right
caudal iung lobes, seenbest on the left lateral radiograph). In
the cat, the additional changes might include a horizontally
oriented heart and a tortuous descendinsaorta.
6. B
7. Between the left and right caudal bronchi.
8, Air bronchogram;atelectasis
and consolidation.
9. The cranioventral reflection is where the ventral portion of the
left cranial lung lobe (linguia) crossesthe midline from ieft to
right; a second reflection occurs where the accessorylung lobe
displacesthe ventral caudal mediastinum to the left. The third
reflection is a fold of mediastinum around the caudal vena
cava (this reflectionis not visible as a separatestructure).
10. A and C
Chapter 26: The Larynx, Pharynx, and Trachea
l. D 2. False 3. Faise 4. True 5. True 6. False 7, False
8. True 9. True 10. True
Ghapter 27 =The Esophagus
l, C 2, False 3. D
4. Radiographic findings:
Zone of reduced radiopacity dorsal to and superimposedon
the cervicaltrachea.
Distinct hypaxial soft-tissue interface in cranial thorax. Ventral
displacementof trachea.
Paired soft-tissuestripes on caudal thorax between aorta and
caudal vena cava on lateral view and on either side of spine
converging at the hiatus of the diaphragm on the dorsoven-
tral view.
Gas-distendedstomach.
Reduced airway through larynx with change in shape of hyoid
apparatus.
Radiographic conclusions:
Megaesophagus.
Gastric dilation.
Soft-tissue swelling of larynx.
Cause:
Acute laryngeal edema with secondaryaerophagiacausing
megaesophagus and gastricdistention.A generalizedneuropa-
thy or toxicity could also result in these findings, but weakness
or other signs of toxicosiswere not reported.
5.C 6.E 7.8 8. D
9. (1) Periesophageal
hiatal hernia. (2) Esophagealdiverticulum.
f0. They provide selection of a suitable radiographic technique,
and they allow assessment of the esophagus,surrounding tis-
sue, and lung to determine coexisting diseaseand rule in or
out the need for contrast examination.
Chapter 28: The Thoracic Wall
l. (A) Presuming satisfactory radiographic visualization of tho-
racic visceral structures (because they are usually very well
contrasted by pulmonary air) using relatively high kVp and
relatively low mAs on initial radiographs (to attempt to reduce
the stark contrast between fluid opacity structures and ribs),
lowering kVp and raising mAs will produce better distinction
among the components of the chest wall (ribs, intercostal mus-
cles, subcutaneous muscles, subcutaneous fat, and intrafascial
fat).
2. (A, B, C, and D) Each of these may produce the "extrapleural
sign" by medial displacement of the parietal pleura. Soft-tissue
swelling(i.e.,hemorrhage,edema)associated with fracturedribs
is less dramatic and must be radiographed tangentially to be
appreciated fully.
3. False.Stippled mineralization of costal cartilagesis a normal
aging change,and is common.
4. Image interpretation: The major radiographic signs are in-
creasedopacity, periosteal reaction, and end-plate lysis involving
the fourth and fifth sternebrae. There is also a mild associated
extrapleural sign dorsal to the affected sternebrae. The final
diagnosis was osteomyelitis of the sternum.
Chapter 29: The Diaphragm
l. (1) The position of the x-ray tube, that is, over the thorax or
abdomen; and (2) The position of the animal, that is, ventral
or dorsal recumbency.
2, The diaphragmaticcrus closestto the table is dispiacedcrani-
ally.
3, Any substanceof soft-tissueopacity adjacent to the thoracic
surface of the diaphragm will obliterate the outline.
4. (1) Cranial displacementof abdominal organs,particularly the
liver, stomach,and spleen;and (2) Cranial or lateral displace-
ment of thoracic structuresby a soft-tissuestructure(s).
5. Hiatal hernia, pulmonary mass,diaphragmaticmass.
6. Esophagram.
7. A scalloped ventral diaphragmatic margin is noted on the
lateral thoracic radiograph.
8. Radiographic signs-lateral view:
The cranial diaphragmaticborder is not visibie.
The caudal cardiac border is not visible.
Focal gas opacities are noted in the caudal ventral thorax,
suspectfor small-bowelloops.
Radiographic signs-ventrodorsal view:
The mediastinrm (solid arrow) and heart are displaced to the
left of midline.
There is a soft-tissue opacity in the caudal right thorax.
Focal gas opacities are noted in the caudal right thorax, suspect
for small-bowel loops (open arrows).
Specific or differential diagnosis:
Traumatic diaphragmatic hernia with abdominal organs in the
caudal right thorax.
Loculated pleural fluid or soft-tissue mass in the caudal right
thorax.
Possiblelung mass in the caudal right lung lobe.
9. (1) Right and 1eftlateral decubitusviews to seeifthe diaphrag-
matic border can be visualized; (2) Filling the stomach and
small bowel with contrast material (barium upper GI study);
(3) Positive-contrastperitoneography;and (4) ultrasound

t0. The following signs confirm the diagnosis:
On the right lateral decubitusview; left side up (seeFig'
2g-23A), the thoracic border of the diaphragm is visual-
ized (arrows), and air-filled lung is in the caudal left tho-
rax.
On the left lateral decubitusview; right side up (seeFig.
29-238), the thoracic border of the diaphragm is not
visualized, and there are soft-tissue and gas opacities in
the caudal right thorax.
On the ventrodorsal view made after contrast material
administration (see Fig. 29-24), the pyloric antrum and
small bowel filled with barium are visualized in the right
caudalthorax.
Chapter 30: The Mediastinum
l, (A) The mediastinum is not a closed space'It communicates
with fascialplanesof the neck and the retroperitonealspace.
2, The cranioventraland caudoventralmediastinalreflectionsare
commonly visualized.
3. Becausethe mediastinum is essentiallya midline structure, it
is much easier to assessit in ventrodorsal or dorsoventral
views. In lateral radiographs,the mediastinum is viewed en
face, and it is not possible to tell if a mass is within or
superimposedon the mediastinum.
4. The foltowing radiographicsignsindicate that the opacity seen
cranial to the heart is in the mediastinum.
a. Compressionof the tracheaon the lateral view.
b. Mass is on the midline on the ventrodorsalview
c. The tracheais displacedto the left on the ventrodorsalview.
5. Pneumomediastinum.There is visualizationof the adventitial
surfaceof the trachea and esophagusand cranial mediastinal
vessels.Thesesigns are consistentwith pneumomediastinum.
6. Peritoneallymphatics drain into the sternal lymph node. In
this dog, barium might have become trapped in the sternal
lymph node, thereby increasingits radiographicopacity.
7. A horizontal-beamventrodorsalthoracic radiograph of medi-
astinal sonography.
8. An intrapulmonary lacerationwith retrogradedissectionof air
along peribronchialand perivascularspacesinto the mediasti-
n um.
9. False.Pneumothorax does not progressto pneumomediasti-
num, but the opposite is true.
10. True. There may be elevation,depression,or no changein the
position of the trachealbifurcation in dogs with tracheobron-
chial lymphadenopathy.
Ghapter 31: The Pleural SPace
l.A
2. False.In ventrodorsalradiographs,the fluid has more opportu-
nity to enter an interlobar fissure and be struck tangentially by
the x-ray beam. In dorsoventralradiographs,the fluid collects
just dorsal to the sternum.
3. False.A straightfluid line will only be seenwhen a horizontal-
beam x-ray beam is usedand there is a free gas-freefluid inter-
face.
4. (l) Retraction of lung margins from the thoracic wall with
soft-tissueopacity betweenlung and thoracic wall' (2) Visual-
ization of interlobar fissuresof a soft-tissueopacity.(3) Silhou-
etting of the diaphragm by an intrathoracic soft-tissue opacity.
ANSWERS 7?5
5. The dog was in dorsal recumbency.If the dog had been in
sternal recumbency,the heart would not be visible becauseof
the effusion collectedaround it.
6.C
7. Trre. Visualizationof interlobar fissuresis more common with
pleural effusion.With pneumothorax, the pulmonary collapse
preventsgas from entering the pleural space.
8. Three radiographic signs of a tension pneumothorax are: (1)
A contralateralmediastinal shift. (2) Caudal displacementof
the diaphragm,possiblywith visualizationof the costalattach-
ments of the diaphragm. (3) Complete collapseof the lung
againstthe hilum.
9. Two things that can be confusedwith pneumothorax are: (l)
A skin fold. (2) The thoracic wall conformation of chondro-
dystrophoid breeds.
10. The concaveaspectof costal is cranial, whereasthe concave
aspect of interlobar fissuresis caudal.
Ghapter 32: The Heart and Great Vessels
l. The range of normal patient sizesis large,various breedshave
markedly different thoracic anatomic conformation, and it is
difficult (if not impossible) to routinely correlateprecisepa-
tient positioning, maximum thoracic inflation, and cardiac
cycle with radiographicexposure.
2. (A) and (C) are reliableradiographicsignsofleft atrial enlarge-
ment, provided that the patient was positioned without obliq-
urty.
3. A decreasein the tracheovertebralangle in the lateral proiec-
tion is not a reliableindication of left atrial enlargementwhen
there is a large volume of free pleural fluid.
4. False.Enlarged pulmonary veins signifu elevatedpulmonary
venous pressure but heart failure is not present until fluid
exudes from the pulmonary capillariesinto the lung paren-
chyma. Many patients with controlled heart diseasehave en-
larged pulmonary veins.
5. (B), (E), and (F) are commonly seenin left-sidedheart failure.
However, (B) and (F) without (E) are also commonly seenin
dogs with compensatedleft heart enlargement-that is, no
left-sided heart failure, whereas alveolar pulmonary infiltrate
causedby cardiogenicpulmonary edema is a reliable sign of
left-sidedheart failure.
6. A, B, C, and D
7. Survey radiographic signs associatedwith PDA include:
Segmentaldilation of the proximal descendingaorta
Dilation of the main pulmonary artery segment
Left atrial dilation
Elongation of the heart
Enlargement of pulmonary arteries and veins
Survey radiographic signs associatedwith aortic stenosisin-
clude:
Widening of the caudalaspectof the cranial mediastinum
(due to poststenotic dilation of the aortic arch)
Elongation of the left ventricie in the dorsoventrai view
and distortion of the junction between the heart and
cranial vena cava in the lateral view due to poststenotic
dilation of the ascendingaorta and aortic arch
Survey radiographic signs associatedwith pulmonic stenosis
include:
736 ANSWERS
Dilation of the main pulmonary artery
Right ventricular enlargement
8. Survey radiographic signs associatedwith heartlvorm disease
include:
Dilation of the main pulmonary artery
Right ventricular enlargement
Dilation of the right and left pulmonary arteries with
truncation ("pruning") and possible arterial tortuosity
Possiblesigns of dght-sided heart failure (e.g., ascites,
hydrothorax)
Survey radiographic signs associatedwith mitral insufficiency
include:
Elevation of the left main stem bronchus and enlargement
of the left atrium
Decreasein the tracheovertebral angle (enlarged left ven-
tricle)
Possiblecaudodorsal unstructured interstitial and alveolar
pulmonary infiltrates (pulmonary edema)
Possibledilation of pulmonary veins
9. Radiographic interpretation of Figure 32-27. Left lateral and
ventrodorsal thoracic radiographs of a 9-year-old neutered
male Golden retriever dog with progressivelethargy and exer-
cise intolerance.The major radiographic sign is globoid en-
largement of the cardiac silhouette. Necropsy revealedthe pres-
ence of a large amount of hemorrhagic fluid in the pericardial
sac due to a mass involving the wall of the right atrium
(histopathologicdiagnosis-hemangiosarcoma).The tracheais
displaced to the right in the ventrodorsal view possibly as a
result of the heart base mass. Radiographic diagnosis: pericar-
dial effusion.
10. Tiue.
Chapter 33: The Pulmonary Vasculature
1. (A) On the left lateral recumbent thoracic view, there is right
cranial lobar pulmonary arterial enlargement as the artery is
larger than its counterpart vein. On the dorsoventral view,
both caudal lobar pulmonary arteries are larger than the 9th
rib at their intersection. The right caudal lobar pulmonary
artery is more enlarged than the left. There is also main
pulmonary artery enlargement and right heart enlargement.
The diagnosis is heartworm disease.
2. (B) Mitral insuffrciency was documented on two-dimensional
echocardiographyand a mitral murmur was heard on ausculta-
tron.
3. (C) Both caudal pulmonary arteries and veins at their site of
intersection with the 9th rib are larger in diameter than the
rib width. A ventricular septal defect was apparent when the
heart was examined with two-dimensional echocardiography.
The pulmonary arteries and veins are enlarged because of
volume overload associatedwith the left-to-right shunt.
4.c s.B 6 .A 7. A 8. B 9. A r 0. c
Chapter 34: The Ganine and Feline Lung
l. None of these is correct. Localized pulmonary lesions, includ-
ing nodules, are normally most visible when the patient is
radiographed with the affected side uppermost (i.e., when the
lesion is in the nondependent lung). If the patient is large,
some magnification of lesions in the nondependent lung may
be apparent owing to geometric distortion.
Obesity-reduces radiographic contrast by increasing scattered
radiation; tends to reduce visibility of intrathoracic structures,
such as the cranial lung lobes; necessitateshigher radiographic
exposures, which may lead to underexposure or excessively
long exposuretimes.
Brachycephalicconformation-often associatedwith obesity;
poor conformation of the upper airway in many brachycephalic
dogs may contribute to underinflation of the lung.
Prolonged recumbency-may result in collapse of the de-
pendent lung, which can obscure lesions.
Movement-owing to rapid breathing, panting, coughing,
or voluntary patient movement may result in motion blur,
which obliterates fine detail on radiographs; hence, small le-
sions may become invisible.
There is a rounded soft-tissue mass (or large nodule) in the
right lung, probably in the caudal lobe; the borders of the mass
are distinct, indicating a sharp demarcation between the lesion
and adjacent aeratedlung; the mass is located in the periphery
of the lobe, but no lesions are apparent in the adjacent ribs.
Differential diagnosis for a solitary pulmonary mass should
include (seeTable 32-2):
Primary lung neoplasm
Pulmonary metastasis
Granuloma
Fluid-filled bulla
Hematoma
Abscess
Cyst
The right caudal lobe was removed surgically.The histologic
diagnosis was bronchoalveolar carcinoma.
4. Opacity of the lung is greater at peak expiration than inspira-
tion becauseair (the lucent component) is expelled.An expira-
tory thoracic radiograph may be useful when a small-volume
pneumothorax is suspected because this maximizes contrast
between the lung and air-filled pleural space.
5. Pulmonary vesselsseen end on are:
Smaller than the nearest side-on vessel
Smaller in the periphery of the lung
Lessnumerous in the periphery of the lung
In contrast, pulmonary nodules may be:
Larger than adjacent vessels
Large in the periphery of the lung
Anywhere in the lung
6. If the appearance of the lesion changes markedly within 24
hours, it is more likely to be the result of fluid in the lung
(e.g.,edema,hemorrhage)than of cellular infiltrates.
An increase (or decrease)in size indicates that the diseaseis
progressing (or resolving) rapidly.
7. Tiue. Aspiration bronchopneumonia frequently affectsthe ven-
tral parts of the lung; lesions in the ventral part of the lung
are often most visible on a ventrodorsal radiograph becauseof
the combined effects of optimal aeration of the nondependent
lung and geometric distortion.
8. The pulmonary pattern is mixed: the left cranial lobe is uni-
formly opacified compatible with an alveolar pattern; the Ieft

caudal lobe has a diffuse interstitial infiltrate that obscuresthe
vesselsand cardiac border; nodules are visible in the left lateral
radiograph, presumably in the right cranial iobe. Note that the
.onsolidited left cranial lobe is not visible on the left lateral
radiograph.
The other relevant radiographic sign is mediastinal shift to
the right; this indicates that the left-sided lesion is expansiie.
This dog died. The pathologic diagnosis was primary carci-
noma in the left cranial lobe with intrapulmonary metastasis.
e. (A) 4 (B) 3 (c) 2 (D) 1
10. Differential diagnosesfor pulmonary calcificationinclude:
Bronchial calcification
Heterotropicbone
Calcified mass (e.g., granuloma, primary neoplasm,me-
tastasis)
Diffuse interstitial calcification (e.g., associatedwith hy-
peradrenocorticism, hyperparathyroidism, chronic ure-
mia)
Idiopathic(seeTable34-6)
I Section Vl:
I Neck and Thorax- Equidae
Chapter 35: Larynx, PharYnx,
and Proximal AirwaY
l. Epiglottic dysfunction can be evaluatedby employing laryngog-
riphy. Contrast medium is administered orally, the horse is
allowed to swallow and images of the pharynx and proximal
airway are made. If contrast medium is present in the larynx or
trachea, the epiglottis is functionally-and often anatomically-
abnormal. However, the absenceof upper airway opacification
does not exclude the possibility of laryngeal dysfunction in that
the epiglottis may be abnormal but still prevent contrast me-
dium from entering the larYnx.
2. (G) none of the above
Pharyngitisproducesno radiographicallyvisible alterationsin
the pharynx, and thus is tlpically associated with a normal
radiograph.
3. Epiglottiditis is rlpically an acute inflammation of the epiglottis,
often infectious, which may causeproximal airway obstruction,
especially in foals.
-Radiographic
recognition of epiglottiditis is entirely depend-
ent on the amount of resultant epiglottic enlargement. Accord-
ingly, severe inflammation is most apt to be detected radio-
griphically, and mild inflammation will likely go unobserved.
4. The most common causeof laryngeal calcification is age-related
metaplasia,which does not affect largrgeal function.
Dystrophic calcification, on the other hand, tlpically occurs
following tissue injury and is more likely to be relevant to
largrgeal function.
5. Superimposition is the major limitation. Lateral imaging of the
guttural pouches results in additive subject opacities.This means
ihut utr iir-distended pouch makes the adjacent normal pouch
appear darker; a partially fluid-filled pouch makes the nearby
normal pouch appear lighter. Thus there is often uncertainty as
to which pouch is diseasedunless there is external swelling.
Ghapter 36: The Equine Lung
l. Pleuropneumonia is a combined infection of the lungs and
pleura. It is generally believed that pleuropneumonia begins in
ANSWERS 737
the lungs and subsequentlyextends to the pleura. Pleuropneu-
monia is obviously worse than pneumonia becauseof its pleural
component. Pleurisy (infection of the pleura) directly affectsthe
ability of the lungs to expand and indirectly impedes inflation
through fluid build-up in the pleural space.When large volumes
of pleural fluid are present, radiographic evaluation of the lung
may not be possible. In such instances-and assuming there is
consolidation of portions of the lung surface-sonography can
be used to confirm lung involvement, although it is not always
possible to differentiate consolidation from atelectasis.
2. The visible blood vesselsof the lung are useful indicators of
both the general and regional circulation. For example, if the
lung vesselsare small and few in number, and the heart is also
small, then the cause may be a smaller than normal blood
volume (e.g.,shock).If the vesselsare large and more numerous
than normal and accompaniedby cardiomegaly,then the blood
volume may be increased(e.g.,heart failure).
Pneumonia often results in a regional pulmonary hlperemia.
Emphysema is usually associatedwith a generalizedpulmonary
oligemia. The absenceof major arteries implying thrombosis is
extremely difficult to detect using only lateral radiographs. The
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
is unreliable.
3. Lung abscess.
4. The large size of the subject and the inability to obtain a
ventrodorsal projection of the thorax.
5, True.
6. Becauseof the inability to obtain a ventrodorsal or dorsoventral
projection of the thorax.
7. Dorsocaudallung field.
8. Ventral lung field.
9. By obtaining radiographs with the left and right sides of the
thorax adjacent to the cassetteand determining in which radio-
graph the lesion margins are most distinct.
Chapter 37: The Pleural Space
1.A 2.C
3. The descending aorta can be seen with improved detail, the
dorsal margin of one lung border is retracted ventrally, and a
lung margin is displaced cranially from the diaphragm. Free
air is present in the left pleural space but no etiology is
apparent. Radiographic diagnosis:pneumothorax, etiology un-
known.
4.D 5.D
6. A fluid line (fluid-air interface) is superimposed over the tra-
chea, and there is loss of detail of the heart and vesselsventral
to the fluid line. The cranial dorsal margin of the aorta has
improved detail causedby free air in the cranial, dorsal pleural
space.Pleural effusion and pneumothorax are present.
7.8 8.C 9.A
10. The diaphragm is concave and has been displaced caudally by
lung with increased air voiume and detail. Caudal to the
heart is a thick tissue opacity extending to the diaphragm and
outlining the irregular margin of an air-filled compartment.
These findings are the result of cavitary diseasesuspectedto
be contained in the pleural space because of the absence of
obvious pulmonary disease.Findings and assessmentwere doc-
umented by the use of ultrasonography and pleuroscopy.
73,A ANSWERS
t Section Vll:
S Abdomen-Gompanion
n Animals
Chapter 38: Interpretation Paradigms for the
Abdomen-Canine and Feline
l. (a) Liver. (b) Fundus of stomach. (c) Left kidney. (d) Spleen.
(e) Urinary bladder. (f) Descendingcolon.
2. Liver-true.
Gallbladder-false.
Pancreas-false.
Prostate-true.
Kidneys-true.
Ovaries-false.
3. (a) Ultrasound. (b) Nuclear scintigraphy.(c) Computed tomog-
raphy.
4. Kidney-2.5 to 3.5 times the length of L2 compared with the
VD view. Small intestine-no wider than the central portion of
the body of a lumbar vertebra, and not to exceedthe diameter
of twice the width of a rib.
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
be no wider than the central portion of the body of L4.
Chapter 39: Abdominal Masses
l. Those structures that are nearly always seen in abdominal
radiographs include the stomach, the liver, the urinary bladder,
the small bowel, and the colon.
Those structures that are often only partially seen are the
spleen,the kidneys (especiallythe right kidney in dogs), and
the prostate gland.
Those structuresthat are seldom seenunlessthey are abnor-
mal include the pancreas,the adrenal glands, the ovaries, and
the mesentericlymph nodes.
2. The head of the spleen is attached to the stomach by the
gastrosplenic ligament. The rest of the spleen is free to move
around in the abdomen, between the bodv wall and the rest of
the viscera.Therefore,the spleenis better seen (radiographi-
cally) with the patient in right lateral recumbency becausethis
position allows the body and tail of the spleento swing across
the ventral midline where it is seen caudoventral to the body
of the stomach and cranioventral to the urinary bladder. With
the patient in left lateral recumbency, the spleen slips between
the bowel and the dependentbody wall, where it "disappears"
because no part of its edge is presented tangent to the x-
ray beam.
3. (B) Positionalradiography
This should be consideredbefore any of the other choices
because it is both cheaper and quicker and because it may
provide displacement information that is significant in the
differential diagnosis.
4. (C) Upper gastrointestinalseriesand (D) sonography
These may provide significant information in differentiai
diagnosticassessment of a right cranioventralabdominal mass.
Neither excretory urography, cystography, nor urethrography
is very helpful in assessment of such a lesion.
5. The stomach, the urinary bladder, and the uterus all undergo
considerablenormal variation in size.
6. (A) Right lateral aspect of the liver
None of the other choices should be expected to create
the described displacement of adjacent structures. Pancreatic
massesshould displacethe descendingduodenum laterally and
should pull it ventrally. Masses of the right kidney should
displace the descending duodenum ventrally. Colic lymphade-
nopathy should pull the transverse and ascending portions of
the colon ventrally. Massesin the root of the mesentery should
displace the small bowel peripherally.
7. (D) Ail of the above
Masses originating from the left kidney, the left 13th rib,
and the left sublumbar muscles all should be expected to
produce the describedvisceral displacements.Make sure to try
to find the kidney; if you cannot, a left kidney mass is the
most likely choice for the described displacement.
8. (Fig. 39-24) The radiographic signs include mild ventral dis-
placement of the descending duodenum and caudal and left
displacementof the jejunum. Histopathologic diagnosiswas
severe,suppurative, subacute pancreatic necrosis that was ob-
structing the common bile duct. Bowel displacement in this
caseis typical of pancreaticmasses.
9. (Fig. 39-25) The radiographicsignsinclude poor serosaldetail
and the suggestion of mass effects in the caudal and lateral
aspectsof the abdomen. Surgicalexploration revealedtorsion
and hemorrhagic distention of both horns of the uterus. The
patient made a complete recovery after ovariohysterectomy.
f0. (Fig. 39-26) The radiographic signs include multiple small
soft tissue metallic opacities (shotgun pellets-probably an
incidental finding of no current clinical significance)and a
large dorsal left fluid opacity mass displacing the descending
colon and small intestine ventrally and medially. Histopatho-
logic diagnosiswas renal carcinoma.
Chapter 4O: The Peritoneal Space
l. Abdominal effusion
There is increasedfluid opacity within the abdomen causing
severeloss of serosalsurfacevisualization.Also, the abdomen
is pendulous. The final diagnosiswas hepatic atrophy, portal
fibrosis, and intrahepatic and extrahepatic portacaval shunts.
The peritoneal fluid was causedby portal hypertension.
2. Sublumbar lymphadenopathy and small liver
There is a soft-tissuemass in the retroperitonealspaceven-
tral to the caudal lumbar vertebra and dorsal to the colon,
which is displaced ventrally. The stomach and small intestine
are located more cranially than usual, indicating decreasedliver
size. Final diagnosis:lymphosarcoma.The causeof the small
liver was not determined,but the primary rule-out was fibrosis.
3. (B) Lateralview, patient in dorsal recumbency
4. (C) Abdominal mass
5. Blood, urine, inflammation (abscessation)
'6. (A) Mediastinum and (B) pelvic canal
7. (A) Adrenal glands, (B) sublumbar lymph nodes, and (D)
caudal surface of the diaphragm.
8. There is loss of serosal surface visualization in the midventral
abdomen. Gas is seen in the craniodorsalabdomen outlining
the liver lobes (seeFig. 40-188). Free gas is also seenon both
views as thin radiolucent lines between the stomach, liver. and
diaphragm. Radiographic diagnosis: free peritoneal gas and
focal peritoneal fluid/peritonitis compatible with intestinal
rupture.
A horizontal-beam radiograph (see Fig. 40-19A) was made
to confirm the presence of free gas. At surgery, a string of
foreign body extending from the duodenum to the cecum
was found. It had eroded throueh the mesenteric surface in
severalplaces.

t. usually an incidental finding with no clinical signifi-
H:.lr
10. Lesssensitive.
ll. (A) Biliary dilation, (C) discretehypoechoicnodules,and
(D) peritoneai fluid occur with both conditions, but
(B) diffuselyhlpoechoic pancreasis more common in pancre-
atitis.
12. Abnormal lymph nodes are usually enlarged, rounded, and
hlpoechoic.
13. False.
The contralateral adrenal gland is usually normal in size.
Chapter 41: The Liver and Spleen
1.D 2.C 3.C 4.8 s.E
6. Phenothiazines,barbiturates
T.Aa nd D
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
Ghapter 43: The Urinary Bladder
l. No. There is no clinical correlation with abnormal clinical
signs when the urinary bladder of a dog is located partially
within the pelvic canal.
2. Displacement of the bladder caudally or ventrally from the
normal location; or no urine within the bladder post voiding.
3. The lucent area is gas within the urinary bladder. It is in the
center of the bladder becausewith a lateral recumbent position,
the highest part of the bladder is the center on the up side.
Calculi are either more opaqueor of the sameopacity as urine;
therefore,this could not representa calculus.
4. Positive-contrast cystogram.
5. Complete distention of the bladder may obliterate mucosal and
bladder wall lesions.
6. Small air bubbles that may be mistaken for calculi; a large air
bubble that may be mistaken for bladder wall thickening;
multiple adjacent bubbles producing a "honey comb" pattern.
7, A pseudofilling defect has a smooth mucosal surface, and the
borders of the filling defect taper gradually.
8. No.
9. The fi.lling defect in the dorsal bladder is an attach;d fiiling
defect extending into the lumen from the dorsal bladder wall.
The filling defect has a sharply angled border with the bladder
wall on the cranial and caudal margins (arrows), indicating an
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
within the bladder wall can also produce such radiographic
changes,but it is an uncommon lesion.
10. The contrast pattern is an extravasationpattern. Contrast me-
dium is leaking into the peritoneal cavtty (arrows) from the
urinary bladder. This indicates that the bladder (B) is ruptured
or perforated.
Ghapter 44: The Urethra
l. True.
2. False.SeeFigure 44-7. No urethrogram is necessaryin this pa-
tient.
ANSWERS 73',
3. The radiographic diagnosis is multiple, variably sized, radio-
paque urethral calculi and a greatly distended bladder that is
Iikely due to urethral obstruction. Calculi are also present in
the bladder, and the prostate gland is enlarged.
4. (D) Barium and oil-basedcontrast media should not be used
for urethrography. Room air and carbon dioxide are negative-
contrast agents.
5. True. Distention of the prostatic urethra is especiallyimproved
if the bladder is fully distended when the urethrogram is
performed.
6. False.
7. False. Prostatic hlperplasia would cause extramural compres-
sion of the urethra, not an intraluminal filling defect.
8. Neoplasia, inflammatory disease,and scar tissue from prior
urethral surgery.
9. False.
10. Tiue.
Chapter 45: The Prostate Gland
1. Generally, the prostate enlarges slowly throughout life in the
male dog.
2. Displacement with paraprostatic cysts is quite variable and no
set rules can be established. Generally, the displacement is
cranial, but there is tremendous variation in individual pa-
tients.
3. Loss of a distinct margin of the prostate in patients with acute
prostatitisis due to a low-grade regional peritonitis secondary
to inflammation in the prostate. It is usually not septic but
may be so in some patients.
4. Asymmetrical placement of the urethra within the prostate is
a sign of a mass lesion, such as a cyst, abscess,or tumor. This
is not seen with benign prostatic hypertrophy. Conversely, a
centrally placed urethra is unusual with prostatic mass lesions.
5. The testiclesand the urinarv bladder.
6. Fat.
7. Increased.
8. This is a normal finding.
9. A stricture of the prostatic urethra is a poor prognostic sign.
Becauseof the central placement of the urethra in the prostate,
it is generally not constricted in benign disease.A stricture
may result from scarring but is very difficult to treat in many
cases.Typically, it is a finding associatedwith neoplasia.
10, Mineralization.
Ghapter 46: The Uterus, Ovaries, and Testes
r.E 2.D 3.E 4. E 5.8 6.E 7. E 8.B 9.D 10.E
Chapter 47=The Stomach
l. (B) Manual restraint is preferred if possiblefor routine gas-
trography to avoid effects on the stomach induced by chemical
restraint drugs.
2. (D) The right recumbent lateral view and the dorsoventral
view made in ventral recumbency both place the pyloric por-
tion of the stomach in a dependent position and thus best
of the pyloric antrum with liquid contrast me-
Xtf;. "ttnt
74O ANSWERS
3. (D) Although at 40 minutes there is a slight delay in initiation
of gastric emptying, the stomach then proceedsto empty in a
normal manner. The technical procedure used in initiating the
study most likely accounts for the initial delay through psychic
factors. Thus the initial delay is of doubtful significance.
4. False. Routine gastrography is preferably performed with liq-
uid barium sulfate.Most water-soluble, organic, iodinated con-
trast media formulated for the alimentary tract can induce
adversephysiologic effects.Newer iodinated contrast media of
lower osmolality are expensivefor routine gastrography.
5. (D) The sequenceis as follows: right lateral, left lateral, dorso-
ventral, and ventrodorsal. A, In right lateral recumbency, the
liquid barium sulfate fills the dependent pyloric portion ofthe
stomach, and gas rises to the fundus. B, In left lateral recum-
bency, the liquid barium sulfate fills the dependent fundus and
body and gas rises to the pyloric portion of the stomach. C In
the dorsoventral view in ventral recumbencv,the licuid barium
sulfatefills the dependentpyloric portion of the stbmach,and
gas rises to the fundus. D, In the ventrodorsal view in dorsal
recumbency, the liquid barium fills the dependent fundic and
pyloric portions of the stomach, and gas rises acrossthe body
of the stomach.
6. The stomach is greatly distended with gds and some fluid. In
left recumbency (A), the gas outlines a round portion of the
stomach representingfundus and body of the stomach, but the
pyloric portion of the stomach is not identified becauseit is
filled with fluid. In right recumbency (B), gas rises to outline
the pyloric portion of the stomach, which indicates that the
pyloric portion of the stomach is located on the left side. Fluid
shifts to more uniform distribution throughout the body and
fundus of the stomach. The pylorus is displaced dorsally and
to the left, and the fundus and body are displaced ventrally
and to the right. Changesindicate gastric volvulus.
7. (A) The stomach is shifted in position such that the body and
pylorus of the stomach are displaced caudally. This pattern of
displacement is characteristic of hepatomegaly. Specific cause
of the hepatomegalyis not identified.
8. (E) In this dog, the stomach has emptied very little after 4
hours. A little of the contrast medium has exited the stomach,
but the bulk of the contrast medium is retained in the stomach.
Thus gastric emptying is significantly delayed. There appears
to be an annular restriction around the pyloric sphincter, but
this is not confirmed on this one image. In this dog, changes
were due to restrictive disease of the pyloric sphincter that
were identified fluoroscopically and at surgery.
9. There is a large, round, sharply marginated filling defect within
the pyloric antrum. At surgery, a large, round rubber ball was
removed from the stomach.
10. There is an annual mural filling defect encircling the pyloric
antrum. There is also an outpouching of luminal barium
sulfate on the cranial surface of the annual filling defect. This
outpouching is an ulcer that is located in the middle of the
annular mass. The duodenum is located more dorsally than
usual, but no significancewas attached. Endoscopic evaluation
of the stomach confirmed the ulcer, and surgery was per-
formed. Final diagnosis was gastric adenocarcinoma with ul-
ceration.
Ghapter 48: The Small Bowel
l. (B) A 14-year-old cat with anorexia and severe weight loss,
and (C) A 4-month-old puppy with vomiting and palpable
abdominal mass. Fat is essential for the contrast that allows
visualization of intestinal serosal surfaces. Anything that se-
verely reduces the amount of intraperitoneal fat (such as ani-
mals younger than 6 months of age and animals with severe
weight loss) causesthe bowel surfaces to be poorly defined.
Additionally, peritoneal effusions and crowding of the bowel
loops by space-occupyingmassesreduce bowel serosaldelinea-
tion.
2. False.The string-of-pearlsappearanceofthe duodenum is seen
only in the normal cat, not the normal dog.
Interpretation: There is extensive dilation of the lumen of a
focal portion of the intestinal tract. The diameter of the intesti-
nal lumen is 4.5 to 6 times larger than the height of the central
part of a lumbar vertebral body. These radiographic signs in a
young dog with an acute history of vomiting and a palpable
abdominal mass are most consistent with bowel obstruction
(mechanical ileus). Recommendation:Exploratory laparotomy.
Rationale: Although the source and location of the obstructive
diseasecannot be determined with the available information,
once the diagnosis of obstructive bowel diseasehas been made,
the treatment is the same-surgical intervention. An intussus-
ception was found at surgery.
Abnormal radiographic signs include focal site of irregular,
thumbprint mucosa-barium interface with narrowed bowel lu-
men in the midportion of the descending duodenum. The
remainder of the small intestine as seen on these images is
unremarkable. The apple-core appearanceof the duodenal le-
sion is seen most frequently with abnormalities that originate
in the bowel wall and produce ulceration of the mucosa.
Possiblecausesinclude primary intestinal neoplasia;bowel ul-
ceration secondary to mast cell tumors, uremia, hepatic disor-
ders, recurrent pancreatitis; or granuloma. The diagnosis was
bowel carcinoma.
There is a generalized, mild distention of the stomach and
small intestinal tract with air. Portions of the colon are also air
filled. This appearanceis most consistent with functional ileus,
which may be causedby bacterial or viral enteritis, abdominal
pain, use of anticholinergic drugs, or malabsorption. Further
work-up indicated recent seroconversionto feline immunode-
ficiency virus-positive status. Presumptive diagnosiswas bacte-
rial or viral enteritis secondary to immune suppressionassocr-
ated with feline immunodeficiency virus.
6. Passageof barium through the stomach and small intestinal
segments is abnormally slow. In a normal cat, the stomach
should be empty of barium by I hour post administration. By
3 hours, the stomach and small bowel should both be empty,
with the remaining barium located in the colon. Delayed con-
trast passagecould be due to recent administration of parasym-
pathomimetic drugs, inadequate volume of barium (through
either underdosing or patient vomiting), or functional ileus. In
this cat, barium volume was adequate,and no inhibitory drugs
had been given. Radiographic diagnosis was functional ileus.
The cat was euthanized;necropsy diagnosiswas granulomatous
(noneffusive) feline infectious peritonitis.
7. Administration of an inadequate volume of barium at the
beginning of the study. If the patient vomits the contrast
medium, redosing can often be accomplished without subse-
quent bouts of vomiting.
8. Mechanical obstruction of the intestine could show no radio-
graphic signs on survey radiographs if (1) the obstruction is
only partial; or (2) the obstructing object is radiolucent and is
located in the proximal duodenum. Any air or fluid accumulat-
ing proximal to this site is evacuatedby vomiting.
9. Radiographic signs of pathologically significant filling defects
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
refer to figures; those followed by t refer to
tables.
-A
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
ABCDS mnemonic (fracture follow-up),
1 7 1 - 1 7 2 ,r 7 r f , r 7 2 f
Abdomen, 483-515
canine/feline, 483*515. Seealso Peritoneal
space.
anatomy of, 483-488, 485f-488f, 700f,701f
CT scan of,490492,490f
evaluation steps in, 489-490
f^+ quanLtty qlA
lat ^,,^-rit.';- il1, Jta.
fluid in. SeePeritoneal fluid.
interpretationparadigms for, 483492,
485f492f, 489r
massesin, 493-515, 493f-515f
enteric, 496, 505f, 506f
hep atic, 49 549 6, 498f-500f
mesenteric, 496, 505f, 506f
ovarian, 498, 5lOf
pancreatic,496,5O6f
renal, 498, 507f-509f
retroperitoneal, 498, 507f, 509f
splenic, 496, 502f, 503f
s u D l u m D a r),l J , ) lJr
organ structuresin, 483-488, 4831,4841,
485f-488f, 4891
radiographictechniquefor, 488-489, 4881
489f, 4891
regions/zonesol 483-488, 4831,484t,
485f-487f
scintigraphyof, 491f, 492
ultrasonographyol 490, 490f
Abdominal rvall, 525-528
canine/feline,525-528
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
+ r . , , lf ) r + r a. r , no \,L1_6.
Abscesses
canine/feline
liver affectedbv, 5-14,:.17t-,5'18f,549t
pancreasaffectedb1',)21i,621, 622f
peritoneal spaceatfectedbr', 520f-522f,
524f
stomachdisplacementby, 621, 622f
teeth affectedbv, 8t!-81, 82f
equine
epiglottis affectedbi', 452, '152f
lung affectedby, a69-'170,47Lf,472f,479f
teeth affected by, 96f, 9 t-, 97f
Absorption, 2-3, 2f, 4, 9, 9f
atomic number relatedto, 9, 4344, 43f,43t,
44f
dose differencesdue to, 2-J. 2f
tissuedifferencesin, 2-3, 2f, 4,9, 9f, 4344,
43t, 44f
Acetabulum
canine/feline
anatomy of, 683f
hip dysplasiaaffecting, I9I-194,193f, l94f
osteophltes of, 193f, I94f
e q u m e ,/ z J r
anatomy of,723f
Adrenal glands, 531-536
canine/feline, 531-536
Adrenal glands (Continued)
anatomy of, 486f, 487, 533f
calcification in, 531-533, 533f
cortisol output reflected in, 534-536, 535f,
536f
"dumbbell" and "plump," 534, 534f, 535f
mineralized tumors of, 490f, 531^533,
533f, 536
pheochromoqtoma of, 498, 509f, 533f,
535f,536f
size/shapeof, 534-536, 534f, 535f, 536f
ultrasonography of, 534-536, 534f-536f
Age, fracture healing affected by, 169, 170f,
1 7 3t
Air (atmospheric), sound wave impedance in,
2lt
ql7' -_^'
Jllt, )ZYI Ailgas, 4344,43f, 43t, 44f. Seealso
Pneumothorax.
in canine/feline patients
joint spaceinjection and, 189, l90f
kidney with, 561
liver with, 544, 547f
mediastinal,383-388, 387f, 388f
osteochondrosiswith, 146, I47 f
prostategland with, 595, 597f
retroperitoneal,383-388, 388f
small intestine wall with, 655-656
stomach with, 487-488, 488f
u r i nary bl adderw i th, 573,574f,575f,580f,
582, 583f
u terusw i th,605,608f
"vacuum" sign due to, 146,147f
in equine patients
foredigit containing, 707f, 708f
guttural pouches with, 455-459, 455f-460f
mediastinal, 478480
tracheallesionsand, 460-461, 460f,461f
radiopacity due to, 43-44, 43f,43t, 44f
Airway. See also Trachea.
canine/feline, 3 I 0-3 I 1
equine
fidl cyst blockage of, 9I-94, 93f, 95f
hematoma blockage of, 94, 96f
obstruction of, 9l-94, 456, 457f, 458f
ALARA principle, 3
Alpha particle radiation, 3
Aluminum strip grids, 14-15, l4f, l5f
Alveolar cresr,72,72f
canine/feline,72,72f, 84, 84f
periodontal diseaseaffecting, 84, 84f
Arral canal, canine/feline, 660-662, 661f, 662f,
666f
Anconeal process,147-149, 149f
Angiogenesis,135
Annulus fibrosus, 110-1i1
anatomy of, ll0, 11lf
mineralizationof, I I l-112, 113f
Anode
focal spot size related to,7, 7f
grid positioning reiative to, 14-15, l4f, l5f
pitting of, 6-7
rolating, 5f, 6-7
x-ray tube with, 5-6, 5f, 7f
Antebrachiocarpal joint
canine, 680f-682f
eqluine,702f-706f
Antebrachium, 678f-682f
canine/feline
anatomy of,678f-682f
Antebrachium ( Continued)
fracturesof, 166f, 172f, l76f
Anticoagulants, 437
lung affected by, 437, 44lf
rodenticide containing, 437, 44If
Aorta, 408
canine/feline,408, 409f, 4l0f
diiation of, 407-408, 409f, 4l0f
Aortic arch, 408
canine/feline
dilation of,408
megaesophagusrole ol 336f, 341*342,
341f, 342f
persistent right fourth, 336f, 341-342,
341f, 342f
Aortic stenosis, 4l1f, 413
Apophysis, 136
'Apple core" appearance
femoral neck, 167, 168f,202
villonodular synovitis with, 202
Aprons, safety requirement for, 4, 5
A rachnoi dmembrane,l l 1, 11l f, 112f
Arthritis
canine/feline, 199-202
polyarthritis in, 200*202, 20If
polyarticular, 199-200, I99f , 200t
rheumatoid, 200,200f
septic (infectious), 199-200, 199f, 200t
equine, 2 18-2 19, 242-244, 281-282
septic, 242-2 44, 28 | -282
carpus in, 242-244, 244f
phalangeal, 281-282, 283f
stifle in, 218-219,22Of
rarsusln, zzo, zzor
Artifacts. Seealso Radiographs.
myelographic,l16, l19f
nipples causing,46, 48f
skin-fold causing, 39940f , 40lf
ultrasonographic, 23-27, 24f-27f
Arytenoepiglotticfolds, 45i-452, 451f,454f,
462f
Arltenoid cartilage, 451, 451f, 453f
Ascariasis,648, 650f
Aspergillosis,78, 79f
Astrocytoma,105, l07f
Ataxia, equine, 129-133, 129f, 13lf-133f
Atlantoaxial joint
canine/feline, 690f, 692f, 694f
sublr.rxationof, 100, 100f
equine,724f
ataxia related ro,128-129, l29f
malformation affecting, 128-129, I29f
Atlantoaxial ligament, 62f
Atlanto-occipital joint
canine, 690f, 695f
equine,724f
Atomic number
absorption effects related Io,9, 4344, 43t
photoelectric effect and, 9
Atrial enlargement, 403, 403f, 404f,406f
o %.-
$tt$
rrriiieullii+
Baastrup's syndrome, 103, 104f
Balance
canine wobbler syndrome in, 10i, i23
equine hoof role in, 288-289, 290f
743
7 IA I NDE X

Balance (Continued) Bone (Continued) Calvarium, 7l

equine wobbler syndrome and, 129-133 disordersaffecting,1461,153-155, 153f, canine,65f, 66f,69If
Barbiturates, splenomegaly causedby, 549, 55If 154f equine, 67f
Barium, 662-664 mineralization of, 135-137 hydrocephalus effect on, 72, 73f
in canine/feline patients disordersaffecting,1461,153-155, 153f- Canalogram,myelographyresultingin,
aspiration of, 445, 446f IJ) I r16-120, 1l 9f
bronchi containing, 445, 446f new production sitesoi 138-14l, I39f-I4lf Cancer. SeeNeoplasia.
colon imaged with, 662-664, 664f, 665f amorphous, I39, I40f, l4lf Canine wobbler s1'ndrome, l0I, 123
enema of, 662-664, 664f, 665f Codman's triangle in, 139, l4}f Carcinoma. Seealso Neoplasia.
polyethylene sphereswith, 618, 642-644, columnar, 139, l40f canine/feiinedigital, 182-184, 185f
642t periostealreactionsin, 138-141, I39f-l4lf squamouscell, 182-184, l85f
small intestine wirh, 640-644,64h, 643f- smooth, 138-139, l39f Cardiomegaly, 402-407
646f, 643t radiopacity dre to, 43-44, 43f, 43t, 44f canine/feline
tracheobronchial lyrnph node uptake of ra- r e m o del i ngol 136-137,l 36f breed-related variation vs., 402-407
r e <n r n t i n n nf I 35
dioactivity from, 445, 446f generalized,407,407f
"Beak" sign, pyloric, 628, 628f sound wave impedance in, 2lt inspiration vs. expiration and, 408f
Biliary tract, 544*549 subchondral,137 left atrium in, 403, 403f, 404f
canine/feline rraDecular,lJl left ventricle in, 403,405t,407f
calculi of, 544-549, 547f, 548f tumors of, 179-186 optical illusion indicating, 36f
o b s t r u c t i o no f , 5 4 9, 5 5 0 f digital, 182-184, 184f, l85f right atrium in, 406, 406f
Biologic amplification, ionization-related, 1, infectionsvs., 179-186 right ventricle in, 403, 406f, 407f
2f,3 multiple lesion form ol 182, 183f Cardiomyopathy
Biological Effects of Ionizing Radiation single lesion form of, L79-182, I79f-l8lf canine/feline,415
(BErR), 3 "Border effacement" sign, radiographs with, 46, dilated, 412f, 415, 416f, 4I7f
BIPS (barium-impregnated polyethylene 48f hypertrophic,412f, 415, 417f
spheres),642t "Boundary enhancement" effect, Mach bands Caries, dental, canine/feline, 84, 84f
in canine/feline patients in, 3s, 36f, 248,248f Carpometacarpal joints, equine, TOZf-706f
small intestineimaged with, 642-644,642r Bowel. SeeIntestine. Carpus. Seealso Metacarpophalangealjoints;
stomachimaging and, 6i8 BowJeg (varus) deformity, equine, 241-242, Metacarpus.
Blastomycosis,osteomyelitis due to, 182, l83f 243f canine/feline,l42t
Blood Brachycephalic shape,66-67, 7 l anatomy of, 680f-682f
bo n e s u p p l y o f , 1 6 7 , 1 6 7 f,1 7 9 ,1 8 0 f,lSlf Brain, sound wave impedancein, 2lt arthritis of, 200,200f
Bremsstrahlung, 5
sound wave impedancein,2lt congenital hypothyroidism affecting, 153,
Bronchi
x-ray absorption by, 29, 291 r54f
"Bog spavin,"222 canine/feline, 3 18, 3 19f, 431, 43lf-433f, 43Ir
trauma to, 206f
barium aspiration into, 445, 446f
Bon e , 1 3 5 - 1 3 7 equlne,227-246
calcificationaffecting,431, 43Lf-433f, 43lt
agenesisof, 149-152, l5lf anatomy of, 228, 229f-232f, 702f-707f
dilatation of, 431, 433f, 439f
blood supply ro, 167, 167f cyst-likelesionsof, 238-24I, 241f, 242f
fluid-filled, 442f
injury affecting,167, l67f fractures of, 232-238, 233f, 236f-240f
foreign body (foxtail) in, 437,438f
interrupted, 179, 180f, 181f hypoplasiaof, 241, 242f,243f
inflammation of, 431, 433f, 444f
oe m l n e r a t r z a u oon\ I/zt, r /J- r /o , L /o r infections of, 242-244, 244f, 245f
mediastinalmass affecting,383, 385f
developmentaldisordersof, 1461,149-158 mineralization affecting, 232, 234f, 235f
mucus obstruction of, 436f, 440, 442f
formation of, 135-137, I36f physitis of, 241, 242f, 244f
thickening of, 431, 432f, 433f
e n d o c h o n d r a l 1, 3 5- 1 3 7 ,l3 6 f radiographic examination of, 228, 228f-
equine
intramembranous,137 232f
dilatation of, 473, 474f
fractures affecting. SeeFractures. soft-tissue swelling in, 230-232, 233f-235f
inflammation of, 473, 474f
growth centersof,135-137, I36f synovrarJornrsot, tl /, zJzt, tJ )l
Bronchiectasis
hyperparathyroidism affecting, 137 varus/valgus deformities related to, 241-
canine/feline, 431, 433f, 439f
hypoplasia of, 149-152, ISI| eqine, 473, 474f
242,243f
infarction affecting,179, 180f, lSlf Bucked shins, equine, 249, 249f Cartilage
hip prosthesiscausing,l81f "Bull's-eye" pattern, enteric, 649, 65lf canine/feline
idiopathic polyostotic,179, 180f cells of, 135
neoplasiaassociatedwith, 179, 18lf n costal,393f
infections of, 179-I86, l81f-185f interlobar fissure vs., 393f
digital, 182-184, l85f Calcaneous mineralizationin, 350, 351f
multiple lesion form in, 182, 183f, i84f canine, 686f-689f exosroses or, I)b-l )/r l 5l I
singfe lesion form in, 179-182, l82f eqrine, 716f,717f opacity of, I43, I43f
tumors vs., 179-186 Calcification, 431, 531,-533,595, 631 osteochondral dysplasia role of, 155-158,
interpretation paradigms for, 136f-I4lf, 137- canine/feline r55f-rs7f
145, 142t, r43f, r44f osteochondrosisaffecting, | 46-147, | 47[,
ABC mnemonic for, 143-144 bronchial, 431, 431f433f, 43It 148f
expectedvariations and, 144 g a stri c,631,63l f reral neocore ot, I),/, 15,/I
pitfalls and, 144 prostatic, 595, 596f, 599 equine, 287-288
lamellar, 137 pulmonary, 43I, 43If433f, 43lt phalangeal,27 l, 287-288, 289f
Iesion patterns in, 137-1,41 Calcifiedbodies, 188, 523 Cat. Seealso specifcorgans,anatomicstructures,
benign vs. aggressive,137-1,4I, 138f-141f canine/feline and disorders.
destructive, 137-138, l37f-L39f, l4lf articular, 188, 1881 abdominal massesin, 493-515,5O6f
distinct vs. indistinct transition zonesin, peritoneal,523,525f appendicular skeleton of, 135-207
r40, 141f Calcium hydroxyapatite, bone content of, 135 developmental disorders of, 146-160, l46t
proliferative, 138-141, l39f-l4lf Calatli,544-549, 561, 588, 589 fractures affecting. SeeFractures,canine/fe-
lysis of, 135, 137-139, L37f-139f,r4rf canine/feline Iine.
geographic,138, 138f, 14lf biliary tree with, 544-549, 547f,548f interpretation paradigms for, 135-145,
moth-eaten, 138, 138f, l41f kidney and, 561, 562t, 563f 136f-141f, 142t, t43f, l44f
permeative,138, l39i 14lf urethra with, 588, 589, 590f tumor vs. infection in, 179-186
malformation of, 149-152, l5lf urinary bladder with, 573-575,575t, 580f, joints in. SeeIoint(s); Joint disease;specific
metabolism of, 137 584*58s, sSsf boneor joint.
 INDEX 74]i

Cat (Continued) Colon (Continued) Crus, canine,686f-689f

nasal passagesin. SeeNasal passages,canine/ normal, 660-662, 661f, 662f Crytococcal infections
feline. obstruction of, 665, 667, 667f feline,78,79f
skull of, 75f, 76f, 78f, 79f, 81f-83f, 86f perforation of, 664, 664f rhinitis causedby, 78, 79f
spine of, 57-63,6If, I0o, ll0-125. Seealso radiography of, 660-673 CT. SeeComputed tomography (CT).
Spine, feline. abnormal findings in, 664-670, 665f- Cystitis,canine/feline,573, 574f, 575f, 585, 585f
vertebraeof, 57, 6lf, 98-100, 103, 105 673f Cystography,575-576
Cathode, x-ray tube with, 5-6, 5f, 7f barium enema for, 662-664 canine/feline
Cauda equina syndrome, 110 complications due ro, 662-664, 664f, contrast studies in, 575-577, 576f-5841,
canine/feline, l0I-102, 123 665f 5761,5781,580t
vertebraein, 101-102, 123 compression used in, 662, 663f radiographicsigns in, 576-582, 578t, 579f-
Cecum, 660-662 contrast studies in, 662-664, 664f, 665f 584f, 5801
preparation for, 662-664 5,/Ot-5./6I' )./Ol
canine/feline, 660-662, 66If, 662f, 666f
anatomy of, 660-462, 661f, 662f, 666f swvey,662, 663f Cysts
colitis and, 668f technique for,662-664 canine/feline
intussusception of, 667, 667f redundancy in, 667 aracnnolo, lz>, ttST
spasm of, 664,665f,669 mesenteric,496,5O5f
Cerebrospinal fluid
stricture of,667,668f ovarian, 609, 609f
CT x-ray absorptionby,29,29t
transverse, 660-662, 661f, 662f prostatic, 498,5l2f
magnetization relaxation time in, 311, 32t
Companion animals. See Cat Dog; specific subchondral(joint) bone, 1871 187t, 188
Cervical vertebral malformation-instability
(wobbler) organ, structure, or disorder. equlne
Computed tomography (CT), 28-29 dentigerous, 9l-94, 94f
c a n i n e ,1 0 1 , 1 2 3
basic physical principles of, 28-29, 28f, 29t nasal passage,9I-94, 93f-95f
equine,129-133
Chestnut,equine, 718f, 719f Hounsfield units in, 29, 29t
Chondrocytes,135, l4l image formation in, 28-29, 28f, 29r
e x o s t o s i rso l e o f , 1 5 6 - 1 5 7 ,l5 7 f tissue factors in,28-29, 28f, 29t
D ens,59f,62f
Chondrodysplasia,1461,155-156, 155f, l56f x-ray generation fo6 29
canine/feline, 62f, 66f, 695f
A l a s k am a l a m u t ew ith , I5 5 , 1 5 5 f Contrast
anomalies affecting, 99-100, l00f
Labrador retrieverwith, 155-156 film type affecting, 16-17
equine,724f
Norwegian elkhound with, 155 kilovolt peak (kVp) related to, i5-17, l6f
displacement of, 128-129, I29f
o c u t a r rl ) ) - l ) o milliampere seconds (mAs) related to, 15-17,
Density, radiopacity related to, 43-44, 43f, 44f
ScottishFold cats with, 155, l56f r6f Dental caries, canine/feline, 84, 84f
Chondrodystrophy, 100-101 Contrast media Developer, film processingwith, 17
canine/feline canine/feline Diaphragm, 359-360
dwarfism associatedwith, 100-101 bronchi containing, 445, 446f canine/feline, 308, 308f, 359-375
heart in, 402,402f colon imaged with, 662-664, 664f, 665f anatomy of, 360-361, 360f-363f
intervertebral disc diseaserole ol I I I c ot, 5/5-5dI, 5/61,5/6t,
cy stographluse celect rn, 5/ r, 5/zl
pleural effusion in, 397f s82f gastroesophagealintussusception affecting,
pneumothorax in, 397f, 401 myelographicuse of, 1l4t-116, ll6f-I22f 369-37r, 370f, 37rf, 37 lt
Clock face analogy,heart in, 319-320,320f, small intestineimaged with, 64I,642t, hernia affecting, 364-369
403, 403f 643t clinical signs in, 365
"Cobblestone"appearance,urinary bladder subarachnoid space injected with, 114- congenitally predisposed, 367-368
wltn,5/b, )./vI rL6, rr6f-122f diaphragmatic, 364-368, 364f-369f, 366t
Coccidioidomycosis, osteomyeiitisof, 182 trachea containing, 445, 446f hiatal, 368-369, 369t, 370f, 371f
Codman'striangle, nerv bone production in, equine peritoneopericardial,368, 368f, 3681,
139,140f myelographic use of, 128, l28f 369f
"Coiled-spring" appearance,intussusception subarachnoid space injected with, 128, traumatic, 364f, 365f, 366, 3661,367f
with, 667f L28f motor disturbances affecting, 37t-373,
Collagen Coronoid process 373f
osteogenesis imperfectarole of, 154 canine, 65f, 66f normal, 360-363, 360f-364f
skeletalsystemProduction of, 135 fiagmented, 149, 150f, 15lf radiographic signs related to, 361-363,
Collimator, 10, 10f jawJocking shift of, 74f 361t, 366t, 368t, 369r, 37rt
radiographicuse of, 10, 10f mandibular, 65f, 66f, 74f rlupfiue of,442f
safety use of, 5 ulnar, 149, 150f, 15lf equlne, 4/ /r
Colon, 660-673 equine, 67f Diaphysis,135-137, r36f
canineifeline mandibular, 67f Digits. SeeMetacarpus; Phalanges.
anatomy of, 486f, 488, 660462, 66If, Cortisone arthropathy Dirofilariasis. SeeHeartworm disease.
662f, 666f eqtine, 262-263, 263f Disc disease.SeeIntervertebral disc disease.
ascending, 660-662, 661f, 662f metacarpophalangeal/metatarsophalangeal, Discospondylitis
descending,66M62, 661f, 662f 262-263,263f canine/feline,104, l05f
displacement of, 662, 662f, 665-667, 666f Co u lo mb (C ),2-3 organisms in, 104, 105f
abdominal mass causing, 493-515, 494f- dosagerelated to, 2-3 Dislocation
496f, s0sf-s08f, sr0f-51 3f, 662f, Coumarin, 437, 44If canine/feline, 73,74f, 8l-83, 83f
666f lung affectedby, a37.441f temporomandi bul ar, 73, 74f, 8l -83, 83f
lymph nodes in, 506i 662f,666f rodenticide containing, 437, 44If traumatic, Sl-83, 83f
p r o s t a t eg l a n d in , 5 1 1 f,5 1 2 f,5 9 3 , 5 9 3 f' Coxofemoral joint. SeeHip. Distance
664f, 666f "Cranial drawer" sign, joint displacement with, distortion related to, 15, 15f
urinary bladder in, 661f, 662,662f 188, 198 object-film distance (OFD) as, 12, Izf,13f
enlargement of, 665, 665f, 666f Craniomandibular osteopathy,83-84, 83f, 86f x-ray beam i ntensi tyand, l 0-I2, l l l 15, l 5f
flexuresof, 661f, 662, 662f Cranium, 71-84 Distortion, 45, 45f
herniated,667,669f canine/feline distance from x-ray source causing, 15, 15f
impaction of, 665, 665f bony proliferation affecting, 83-84, 83f Diverticula, urinary bladder with, 577, 582f
inflammation of, 665, 667, 668f, 669, 670f craniomandibular osteopathy affecting, DNA (deoryribonucleic acid), radiation effect
intussusception affecting, 667, 667f 83-84, 83f on, l , 2f
rnegacolon of, 665, 666f neoplasia affecting, 76-77, 77f, 78f Dog. Seealso specificorgans,anatomic
neoplasia of, 667, 669-670, 669f Crena marginis solearis, 271 structures, and disorders.
TIIS INDEX
Dog. Seealso specificorgans (Continued)
abdominal massesin, 493-515, 493f-5I5f
anatomy of, 58f, 676f-70If
appendicular skeleton of, 58f, 135107
developmentai disorders of, 146-160, l46t
fractures affecting, SeeFractures, canine/fe-
line.
interpretation paradigms for, 135-145,
r36f-t4rf, r42t, r43f, l44f
tumor vs. infection in, 179-186
joints in. Seeloint(s); |oint disease;specg1c
bone or joint.
nasal passagesin. SeeNasal passages,canine/
feline.
skull of, 6s-69, 65f-70f,72f-84f, 86f
spine of, 57-63, 58f-65f,98-109. Seealso
Spine, canine.
vertebraeof, 57-63,58f-65f, 98-i09. Seealso
Vertebra,canine/feline.
Dolichocephalic shape,66-67, 7l
Dose (radiation)
absorption differences and, 2-3, 2f
equivalenry in, 3
maximum permissible, 3
units of radiation as, 2-3
"Double physis" sign, 153
Dura m a t e r , 1 1 1 , 1 1 I f , 1 1 2 f
Dwarfism, 100-101
canine/feline
chondrodystrophic,100-l0i
congenital hypothyroidism causing, 153,
r54f
mucopolysaccharidosiscausing, 153-154,
I 55f
primordial, 100
vertebraein, 100-101
Dysphagia, 33I-335
canine/feline,33I-335, 333f-336f
cricopharyngeal, 333-335, 334f, 335f, 336t
oropharyngeal, 331-333, 333f-335f, 3361
pharyngeal, 333-335, 334f, 335f, 336t
Dysraphism, canine/feline, 124
Dystocia, canine/feline, 605-607, 608f
Ear. SeeOtitis; Tympanic bulla.
Edema (pulmonary)
canine/feline, 408-409, 4llf, 412f, 428f, 440f
eqrsine,472473
Effusions
canine/feline
pericardial, 417419, 4L8f
peritoneal. SeePeritoneal fluid.
pleural. SeePleural effusion.
synovial, 187, 187f, 199-205, I99f, 200t
equine,476477
guttural pouches with, 455-459, 455f-459f
Elbow, 1421
canine/feline
anatomy of,677f-680f
dysplasia of, 147-149, I49f-l5lf
fragmented coronoid process in, 149,
l s0f-151f
osteoarthritis of, l92f
sarcoma of,203f,205
sesamoidbones of, 1881,189
ununited anconeal processin, 147-149,
r49f
equine, 720f, 72lf
anatomy of, 72Of,72If
Electric current
alternating vs. direct, 6
rectification of, 6,7f
ripple effect related to, 8, 8f
Electric current (Continued)
transformers for, 7-8, 8f
voltagefluctuation in, 8, 8f
x-ray production role of, 6-8, 8f
Electron volt (eV), 1, 6
Embolism
canine/feline heartworm diseasecausing, 424,
4 2 4 t ,426f
equine pulmonary, 472
Emphysema
canine/feline, 440, 443f, 444f
equine,473,474f
Entenus, o)2, o)4r-b)or
canine/feline, 652, 654f-65 6f
Enthesophytes, l4l, I87f
canine/feline femur with, 187f, l9l,192f,
193f
equine carpus affected by, 245,245f
Epidurography, lumbosacral stenosisin, 123
Epiglottis
canine/feline, 323, 323f, 324f
equine, 451-452, 45lf-454f, 725f
abscessaffecting, 452, 452f
congenital deformity of, 452, 453f
entrapment of, 452, 461, 462f
inflammation oi 452
massesaffecting, 452, 452f, 454f
p o sitionof,451,45l f
Epiphysis, 135-137, I36f
Beagledisorder of, 156, 156f
canine/feline
blood supply to,167, l67f
dysplasiasaffecting, 155-158, 156f
fracture affecting, L63, 163f, L64f
mucopolysaccharidosisaffecting, l54f
equine femoral,723f
Equilibrium
canine wobbler syndrome in, 101, 123
equine hoof role in,288-289, 290f
equine wobbler syndrome in, I29-I33
Ergot, equine, 7L3f, 7l5f
Esophagitis, 336, 344-345
canine/feline, 336, 344-345
gastroesophagealreflux causing, 344-345,
345f, 346f
megaesophagus with, 336, 338f-340f
Esophagus, 329-349
canine/feline, 329-3 49
airlgas in, 326, 326f, 329, 330f, 335, 337f,
343f
anatomy of,329
aortic arch anomalies and, 336f, 341-342,
34rf,342f
congenital disorders of, 341-342, 34If-
343f
fistula of, 344,345f
focal diseasesites in, 346, 347t
foreign bodies in, 335-336, 337f, 338f
gastroesophagealreflux affecting, 344-345,
345f, 346f
hiatal disorders affecting, 344-345, 345f,
346f
inflammation of. SeeEsophagitis.
intussusception affecting, 345-348, 346f.,
347f
megaesophagusof, 335-344
generalized,342-344, 343f, 344f
mineralization in, 336, 338f, 339f
motor diseaseaffecting, 339,340f
neoplasia of, 336, 338f-340f
perforation of, 336, 338f, 344, 345f
radiography of
contrast media in, 329-33I, 33 lf-333f
normal appearance of, 329-331, 330f-
333f, 330t
survey findings in, 3301
Esophagus(Continued)
technique for, 329-331, 33lf-333f
redundancy in, 342, 343f
sphincters of, 329, 330f, 332f
stricture of, 336-341, 337f, 340f
swallowingdisordersand, 331-335, 333f-
336f
trachea affected by, 326, 326f, 343f
vascularring anomaliesof, 34I-342, 341f,
342f
equine,455f, 460,479f
Exercise,equine lung hemorrhage due to, 470,
473f
Exostoses,multiple cartilaginous, 104-105,
156-157,l 57f
Ey"
canrne/Ieltne,l))-l)b
chondrodysplasia affecting, 155-156
human, 39-41. Seealso Radiographs,interpre-
tation of; Visual perception (human).
saccadicmovements of,3941, 4lf
lllllftllti
Face
mucopolysaccharidosisdysmorphia of, 153
shape variations in, 66-67, 71, 72f
Fat
atomic number of, 43-44, 43f, 43t, 44f
canine/feline
abdominal quantity of, 516, 517f, 529f
emaciation and,5l7f
radiopacity due to, 43-44, 43f,43t,44f
sound wave impedancein, 21t
Fat body
canine/feline infrapatellar, 685f
anatomy of, 685f
mineralization in, 203f
synovial volume indicated by, 187, 199f
equine foredigit with, 708f
Femur
canine/feline
anatomy of, 683f-686f
"apple core" appearancein, 167, 168f
aseptic necrosis affecting, 149, lslf
fractures of, 162f, 165f, 167f, 168f, 170f,
t74f, 17sf, r97f
hyperparathyroidism (nutritional) affect-
i ng, 153, l 53f
infarction of, lSlf
osteochondrosisaffecting, 146-147, l48f
panosteitis affecting, 152, I52f
tumor of, 180f, 183f
eqtine, 72lf-723f
anatomy of,72lf-723f
Fetus, 603-607
canine/feline
mummified, 605, 608f
uterus and, 603-607, 604f, 605f, 608f
Fibrosarcoma, canine/feline fracture with, 165f
Fibula
canine/feline
anatomy of, 684f-688f
malformation of, 149-152, I5lf
eqrine, 721f, 722f
anatomyof,721f,722f
Film
blackness/opacity of, 10-12, l}f, lLf, l4f, 42-
44, 42f-44f
common technical errors affecting, 17, l7t,
i 8f
contrast factorsfor, 15-17, 16f,46,48f
darkroom processing of, 17
distortion affecting, 15, lsf, 45, 45f
emulsion of, I0,12, l2f
exposure principles for, 10-17, l0f-16f, l7t

FlIm (Continued)
focal spot size effect on,12, I2f, I3f
fog affecting, 17
grids used with, l4-15, 14f, 15f
i m a g ed e t a i lf a c t o r sfo r , l2 - 1 5 , l2 f- l5 f
intensifying screen for, 13-14, 13f
silver halide crystals of, 10, 12,12f
speedof, 12, l2f
x-ray interaction with, 10-17, I0f-16f, l7t
Filters,x-ray tube with, 10, lOf
Fistula, equine withers affected by,129, l3}f
Fixation devices, fractures with, 165f,
l 6 8 f - l 7 6 f , 1 6 9 - t7 2 , t7 8 f
Fixer solution, film processingwith, 17
Fluid(s)
for canine/feline patients
abdominal. SeePeritoneal fluid.
m e d i a s t i n a l3, 8 3 ,3 8 6 f
pericardial, 416-419, 4l8f
pleural. SeePleural effusion.
synovial, 187, 187f, 199-205, I99f,200r
for equine patients
guttural poucheswith, 455-459. 455t-459t
nletral. 476477. 476f479f
radiopacity gradient tn, 43t, 44
Fluorescence, intensiryingscreenphosphors
with, 13, 13f
FluoroscopSequine, 209
Focalspot
anode relatedto, 7, 7f
radiographic effects and, 12, Izf, I3f
size of, 7, 7f, 12, 12f, l3f
Focalspot-film distance(FFD)
grid focus related to, 15f
image detail affected by, 12, l2f, lsf
kilovolt peak (kVp) relatedto, 10-12, llf
milliampere seconds(mAs) and, 10-12, l0f,
1lf
Fogging, film affected by, 17
Fnr em en
canrne,/ l-/ J, / Jl
occipital d,vsplasia affecting,72-73, 73f
Foredigit,equine. SeeHoof.
Fnr ef nnt ( aa C: r nr r c
Foreign body(ies)
in canine/felinepatients
bronchial foxtail as, 437,438f
megaesophagus due to, 335-336, 337f,
33 8 f
nasalpassagecontaining, 78, 80f
small intestinecontaining, 645-648,646f,
6.18f-6s0f
stomachaffectedby, 621-623, 623f, 624f
thvroid cartilagevs., 323, 323f
in enrrine netients al. 9lf.
nasalpassages affectedby, 91,91f,92f
"Founder" distance,2.84-286,285f
Foxtail, canine/felinebronchi with, 437, 438f
F r a c t u r e sl,6 1 - 1 ; 8
canine/feline,161-178
articular, 195-i96, 196f, I97f
atrophy/demineralizationwirh, 1,72f,173-
176,176f
amlsion with, 162
chip form of, 162-163
classificationof, 162-163, 162f-165f
closedform of, 162
c o m m i n u t e df or m o l lo 2 , lo 2 f, I6 7 i
1 6 9 f ,r 7 3 l
completels. incomplete, 162
condl'lar orientation of, 163
d e l a v e du n i o n o i. l:1 . l;lt- . l;3 t
r lenr ec ( inn f nr m nf l6l
e v a l u a t i o no f , l6 l- 1 6 3 , 1 6 1 f- 1 6 5 i 1 6 9 -
1.72,l70f-I t-2f
f i s s u r ef o r m o f, 1 6 2 , Ib 2 f
Fractures (Continued)
fixation devicesfor, 165f, l68f-176f,169-
r72, l78f
folding form of, 163, 165f
follow-up of, 169-172, lT Of-172f
ABCDS mnemonic for, 17I-172, 17lf,
172f
evaluation in, 169-172, 170f-17 2f
greenstick form of, 162
gunshot causing, 169, l69f
healing of, r65-L76
age effect on, 169, 170f, l73t
anatomic location affecting, 167, l68f
apposition effect on, 169,169f, I7I
blood supply affecting, 167, l67f
compl i cati onsi n, 172-176,17Lt-176f,
178f
modiffing factors in, 166-169, l67f-
170f
motion/stability effect on, 167-169,
r68f, r69f, r72f
primary vs. secondary, 165-166, 165f,
r66f, 166r
soft tissuesin, 172
time line for, I66t, I73t
impacted form of, 162
infection and, 172-173, 174f, l82f
involucrum (sclerosis)with, 4075f
joints affectedby, 195-196, 196f, I97f
luxation with, 163
malunion of, 172, l72f
Monteggia form of, 163
nerve injury &1e to, 173, I75f
nonunl on o\ r/2, t/4r
open form of,162,182f.
pathologic form of, 163, 165f
physeal-metaphyseal-epiphyseal, 163, 163f,
r64f, r68f, L97f
pseudarthrosis following, 172
recognition of, 161, l6If,162f
ribs affectedby, 351, 353f-355f
Salterforms of,163,163f, l64f
sarcomaand,176, l76f
segmental form of, 162
sequestrumi n, 17j , 175[
spiral form of, 162
stress (fatigue) form of, 162
"T" and "Y" forms of, 163, l69f
types of, 162-163, l62f-165f
equine, 2l3f
carpus affected by, 232-238, 233f, 236f-
240f
maxillary, 90f, 9lf
metacarpal/metatarsal, 251-254, 25lt-255f
92f metacarpophalangeal/metatarsophalangeal,
26s-267, 265f, 266f
navicular bone in, 301-302, 302f, 303f
patellain, 219, 220f, 22If
phalangeal, 276-280, 27 8f-281f
stifle affected by, 2l9, 220f, 221f
Free induction decay (FID), 32f
Frog, equine, 708f-710f
*"
'r*1"
.t19UU:i111!Uu
Gallbladder, 484,485f
canine/feline, 484, 485f, 541, 542f, 550f
anatomy of, 484, 485f, 541, 542f
normal, 484, 485f, 54I, 542f
sludge of, 549
stones related to, 544-549, 547f, 548f
ultrasonography artifact of, 24f, 27f.
Gamma rays, 1, 2t
nuclear emission of, I
Gas/fluid. Seealso Airlgas; Effusions; Fluid(s).
canineifeline stomach with, 487-488, 488f
I NDEX 747
Gasifluid (Continued)
equine
guttural pouches with, 455-459, 455f-460f
pleural, 476-47 7, 476f47 9f
Gastric axis, 615,616f
canine/feline, 540-543, 540f, 542f, 545, 546f,
61s,6r6f
liver imaging of, 540-543, 540f, 542f, 545,
546f
stomachevaluationand, 615, 616f
Gastritis, canine/feline, 629f, 631, 63lf
Generators
three-phase,8, 8f
x-ray production by, 7-8
Gingival periodontal disease
canine/feline, 84, 84f
eqrine, 96f, 97, 97f
Glenoid cavity, canine, 676f
Glomerulonephritis, 565f
Gloves, safety role of, 4, 5
Goggles,safety role of, 4, 5
Gray matter
CT x-ray absorption by,29,29t
magnetizationrelaxationtime in, 31t
Gray (Gy) unit, 2-3
rad equivalency for, 2*3
Great vessels,406-408
canine/feline, 406-408, 409f-411f, 413f, 414f
changesin, 406-408, 409f-411f,413f, 4I4f
Grids
alignment of, 14-15, 14f, l5f
anode positioning relativeto, 14-15, l4f, 15f
basic principles of, 14-15, 14f, 15f
construction detail of, 14-15, l4f, l5f
grid ratio of, 14, l4f
radiographicuse of, l4*15, l4f, 15f
types of, l4-I5, l4f, lsf
Gunshot wounds
canine fracturesdue to, 169, 169f
equine pharynx with, 455, 456f
Guttural pouches, 456-459
equrne
anatomy of,67f,725f
distention of, 455-459, 455f-459f
gas/fluid in, 455459, 455f-460f
infection of, 455-459, 455f
larynx and, 451f, 454f, 455f
lymphadenopathy in, 455, 456f
massesin, 459, 459f
pharynx and,, 455-459, 455f-460f
radiographic signs related to, 455f-459f,
456-459
Glmecomastia, canine, 487
IJ
tf
Head. Seealso Nasal passages;Skull.
canlne
anatomy of, 7 l, 689f-694f
brachycephalic, 66-67, 7 1
dolichocephalic,66-67, 7'l
mesaticephalic, 66-67, 7 L 72l
equine, 65*69, 67f, 68f, 725f, 726f
anatomy of, 65-69, 67f, 68f,725f,726f
CT scan of, 68f, 69
nasal passagesoi 87-98
radiographic technique for, 67f, 68f, 87
Heafi,402419
canine/feline, 402-419
anatomy of, 4O2,402f, 408f
chondrodystrophic breeds and, 402, 4O2f
clock face analogy for, 319-320, 320f, 403,
403f
congenital disorder(s) of, 409414
aortic stenosisas, 409i 413
patent ductus arteriosusas,3111 405f,
409
744 INDEX
Heart (Continued)
pulmonic stenosisas, 406f, 409, 413
situs inversus as, 414,415f
tetralogy of Fallot as, 414, 415f
tricuspid dysplasia as, 406f, 414
ventricular septal defect as, 413, 4l4f
enlargement of, 402406
breed-related variation vs., 402*406
generalized, 403, 406, 4O7f
inspiration vs. expiration and, 408f
left atrium in, 403, 403f,404f
left ventricle in, 403, 405t, 407f
right atrium in, 403, 4O6f
right ventricle in, 403, 406f,407f
failure of, 408-413
left-sided, 408, 4llf, 4l2f
right-sided, 409,4r3f
parasitism affecting, 4I0f, 413f, 415
pneumothorax affecting, 397401, 398f-
40rf
small size of,4l8f,4l9
thoracic radiography and, 309f, 318-322,
3r9f-3211
valr.ular disorder(s) of
aortic stenosisas, 410f, 413
mitral insufficiency as, 404f, 411f,414-
4r5, 428f
pulmonary stenosis as, 406f, 409, 413
tricuspid dysplasia as, 406f, 4L4
vertebral heart score measurement for,
318-319
Heartworm disease
canine/feline, 410f, 4I3f, 415
heart failure due to, 408, 413f
hepatomegaly due to, 620f
lung affected by, 435, 435f
pulmonary artery in, 423424, 424f-427f,
424t
thromboembolism due to, 424, 424r, 426f
Hemal arches,57, 6lf
Hemarthrosis, canine/feline, 199
Hematoma
canine/feline spleen with, 503f
equine nasal passageswith, 39, 40f
Hemorrhage
canine/feline
joints affected by, 199
fung in, 437440, 44lf
retroperitoneal, 5 I 9f
equine
diaphragmatic hernia with, 474, 474f
exercisecausing, 470, 473f
Iung affected by, 470, 473f
Hepatic vein, canine/feiine, 541, 542f
Hepatitis, canine/feline, 543, 545f
Hepatomegaly, 495, 497f
canine/feline, 495, 497f, 541-543, 542f-546f,
543t
differential diagnosis in, 54I-543, 543t
generalizedvs. focal, 5431
inflammation with, 543, 545f
stomach displacement in, 485i 543-544,
s45f, 546f, 620f
Hepatozoonosis, 182
osteomyelitis due to, 182
Hernia
canine/feline, 364-3 69
abdominal wall in, 528, 528f,605,607f,
6sr,65lf
diaphragmatic, 364-369, 364f-369f, 366t
clinical signs in, 365
congenitally predisposed, 367-368
esophagusaffected by, 344-345, 345f,
346f
hiatal, 344-345, 368-369, 369t, 370f ,
37r f
Hernia (Continued)
peritoneopericardial, 368, 368f, 3681,
369f
traumatic, 364f, 365f, 366, 366t, 367f
small intestinein, 651, 65lf
umbilical, 528,528f
uterus in, 605,607f
equine,474, 474f
474, 474f
d ia p hragmati c,
pleural air d:ueto,474,474f
Hindfoot. SeeTarsus.
Hip, 142t
canine/feline
anatomy of,683f,684f
asepticnecrosisaffecting,149, 151f
bone infarct affecting, lSlf
distraction methods for, 194-195, 194f,
195f, 1961
dysplasia of, 190-195, I93f-195f, I96t
incidenceof, 191-194
radiographic technique in evaluation of,
194-195, 194f, r95f, r96t,207f
signs in, l9l, l93f-195f,207f
Iaxity index for, 194-195,194f,195f, l96t
normal mature, I93f, I94f
prosthesisfor, lSlf
sesamoidbones of, 1881,189
Hirschsprung's disease,in canine/feline
patients,665,666f
"Honeycomb" appearance,urinary bladder
with, 583f
Hoof, 708f-710f
equine
anatomy of,7\8f-710f
balance of, 288-289, 290f
flexural deformity affecting, 286-287, 287f,
288f
"founder" distance in, 284-286, 285f
front limb, 708f-7I0f
laminitis of, 283-286, 284f, 285f
"ski-tip" appearancein, 284f
"toe dancer" stance in, 286, Z87f
Hormones. Seealso Testes.
bone metabolism affected by, 137
Horse. Seealso specifc anatomic structuresand
disorders.
anatomy of, 58f, 702f-726f
joints of. SeeIoint(s), equtne; specificbones
and joints.
lung of. SeeLung, equine.
nasal passagesof, 87-98. Seealso Nasal pas-
sa8es,equlne.
skeleton of
appendicular,58f, 209-214, 210f, 2I2f,
2r3f
axjal, 57-63,58f, 59f, 63-65, 63f, 65f
interpretation paradigms for, 209-214,
2t0f,2r2f,2L3f
radiographic technique in examination of,
209-2rr,2r0f
skull of, 65-69, 67f,68f, 87-98, 725f,726f
spine of, 57,58f,59f,63, 63f, 65f, 127-133
vertebraeof, 57, 58f, 59f, 63,63f, 65f, 127-
r33,r28f-r33f
Hounsfield units, 29, 29t
Hourglass appearance
disc protrusion causing,122f,123, l23f
spinal cord with, I22f, I23, I23f
Humerus
canine/feline
anatomy of,676f480f
fractures of, 169f, 174f, l78f
in compl eteossi fi cati onof, 157-158,l 57f
infection of, l81f
psteochondrosisaffecting, 146-147, l48f
tumor of, 180f, l83f
Humerus (Continued)
eqtine, 720f, 72lf
4 Id r u r u / ^c
a1i€ a1lc
Hydrocephalus, 69, 72
canine/feline
breeds affected by, 72
calvarium aflectedby, 72, 7JI
ultrasonography of, 69, 69f
Hydromyelia, canine/feline, 124
Hydronephrosis, canine/fe1ine,508f, 56 i, 5611
562t, 563f, s64f
Hydroxyapatite, bone content of, 135
Hygroma, equine carpus wlth, 230,233f
Hyoid bone
canine/feline, 65f, 689f, 692f, 695f
foreign body vs., 323, 323f
equine, 725f
Hyperparathyroidism, 73, 75f, 1,04,l04f
canine/feline
bone metabolism affected b5 73, 103,
104f, 137
fracture related to, 165f
nutritional, 104f, 153, 153f, l65f
osteodystrophydue to, 73, 75f,103, l04f
resorption due to, 73, 75f,103, l04f
Hypervitaminosis A
bony proliferation due to, 103
feline, 103
Hypothyroidism, canine/feline, congenital, 153,
r54f
Ileus, 644-650
canine/feline, 644-645, 646f, 646t, 647f
dilation/distention in, 644-645, 646f, 646r,
647f
functional (paralytic), 647f, 650-652
mechanical, 645.-650, 646f-651f
Ilium
canine,683f, 684f
equine,723f
Infarction, bone, 179, 180i 18lf
Infections
canine/feline
arthritis due to, 199-200, 199f, 200t
bone affected by. SeeOsteomyelitis.
nasal passageswith, 77-7 8, 79f
ribs affected by, 357, 357f-359f
sl ernum In,5>/, JJ9I
urinary bladder with, 573, 574f,575f
vertebrae affected by, 104, 105f
equrne
metacarpophalangeal/metatarsophalangeal,
264-265,265f
navicularbone in, 102-303, l03f
phalangeal, 28 I-282, 28| f-283f
stifle in, 218-219,220f
vertebrae affected by, 129, 130f, 132
Infraorbital canal, equine, 88f, 89
Infrapatellar fat pad, 685f
canine/feline
anatomy of, 685f
mineralization in, 203f
syrovial volume indicated by, I87, l99f
Intensifting screens
..'r^nr/^f t? l?f
phosphorsin, 13, l3f
radiographic effect of, 13-14, l3f
Intensity (I), x-rays per area expressedas,
10-u, 1l f
Interphalangeal joints, 708f-7 11f
eqrline, 272f, 274f , 708f-7 ll f
cartilage of, 27 l, 288, 289f
flexural deformity of, 286-287, 287f, 288f
osteoarthrosis of, 283f
 INDEX 749

Interphalangeal joints (Continued) Iodine preparations (Continued) Ioint disease(Continued)

osteochondrosisaffecting, 287*288, 289f esophagusimaged with, 331 sesamoi dbonesi n, 1881 ,189, 191f
Intertarsaljoints, equine, 7 l6f-7 l9f myelographicuse of, ll4-116, 1I6f-122f sprainsin, 196-f99,197f, l98f
Intervertebral disc disease,110-124 small intestine imaged with, 641, 642t, stressexamination technique for, 196*199,
canine/feline 643t 197f, r98f
anatomy and, 110-111, IIlf, II2f in equine patients, 128 synovium in, 187, 1881,199-205,199f,
chondrodystrophyrole in, 111 myelographic use of, 128, l28f 203f, 204f
disc protrusion in, lll-124, IIzf, ll3f, subarachnoid space injected with, 128, traumatic, 195-199, 196f, I97f
r20t, t21f-r23f r28f equine. Seespecific.ioint or disorder.
laminectomy in, 112-114, 114f Ionization Ioi nt mi ce, 146,187f,188,1881
lesion terminology in, 111-112 "biologic ampiification' associatedwith, l,
m i n e r a l i z a t i o nca u sin g ,I I l- l 1 2 , I l3 f |oule dosageunit, 2-3
2f,3
pathophysiologyof, llo-ill DNA affectedby, 1,2f,3
radiographyin
myelographic,ll4-124, I l5f-123f, I 161,
radiation causing,I, 2f, 3 K
Ischium
1201 Kartagener'ssl.ndrome,415, 4l5f
canine, 683f, 684f
survey,112, II2f, Il3f eqtine,723f Keratoma, equine phalangeal, 289-290
spinal cord compressiondue to, 111 Nroney,55b-5ol
Intestine,639-673 canl ne/Iel l ne, 55b-501,5,/u
canine/feline J abnormalfi ndi ngsi n. 558-562.55qf-561f,
large. SeeCecum; Colon; Rectum. 5621
Jaw |ocking,73, 74f
small, 639-660 canine/feline aD sence ol , 556, 55yI
abdominal massdisplacing,493-515, coronoid process in, 74f ai r i n, 561
494f, 49sf, s04f-s06f, 508f temporomandibularjoint in, 73, 74f anatomy of, 485f-487f, 487, 556
abnormalities of, 644-659, 646t, 647f-
Joint(s), l4I-143. Seealso specificjoint or cal cul iassoci ated w i th, 56 1, 562t, 563f
6s6f, 658f-6s9f disorder. ectopi c,56l
anatomy ol 485f, 486f, 488, 639-640,
canine/feline enlargementof, 496-498,507f, 508f, 560,
640f
calcifiedbodies in, 188, 1881 56tf
barium in, 640-644, 642t, 643f-646f,
developmental disorders affecting, 146- familial diseaseof, 558, 560f
6431
160, l 46t hydronephrosiof, s 560,561f,562t,563f,
BIPS (polyethylene spheres) in, 642-644,
displacementin, 188, 197f, 198f 564f
642t
interpretation paradigms for, l4l-I44, massesassociatedwith, 498, 507f-509f,
contrast examination of, 640-644, 642t,
r42t, t43f s6If
643f-646f, 6$r
lumbosacral degenerativediseaseof, l0l- neoplasia of, 560f
diameter measurementfor, 639, 64Of
103, i 02f nephrographyof, 556, 558-560, 560f, 562t,
dilation/distention of, 644-645, 646f,
osteochondritis dissecansof, 146-147, )b)t
646t, 647f
r47f, r48f normar,5)/-556, 55/t, 55 U 1,55y l
foreign objectsin, 645-648, 646f,648f-
osteochondrosis of, 146-147, 147f, 148f
6s0f opacity patterns of, 561-562,562t,563f*
soft tissuemineralizationin, 1871,188,
n e r n l a t e o b, ) 1, tt5 1 t )bfr
202,203f
i n f l a m m a t i o no f, 6 5 2 , 6 5 4 f 6 5 6 f pheochromocytoma displacing, 498, 509f
spacein, 187
intussusceptionaffecting,647f, 648-649, pyelography of, 556-557, 558f-560f, 562t
air injected into, 189, 190f
b) lI size of, 485f487f, 487, 557,5571,558-560
thickness of, 187, 187f, l99f
i o d i n e p r e p a r a tio nu se din , 6 4 1 ,6 4 2 t, ultrasonographyof, 556-557, 559f, 561f
stressexaminationtechniquefor, 196-199,
6.13t urography of, 556-562, 5571,558f-560i
mucosal surtacein, 652-654, 652f-656f 197f, r98f
synovialchangesin, 187,187f,187t, 199, 562t
neoplasiaof, 652-655, 653f, 655f, 656f quanti tal i vemeasurem ents i n, 557, 557t
normal, 639-644, 640f, 643f-646f 20s,200t
equine, 209-305 techni quefor, 556-557 .556t
obstruction of, 645-652, 646f-651f
atlantoaxial, 128-129, IZ9f, 724f Kiloelectronvolt (keV), 6
parasite(ascarid)in, 648, 650f
carpal, 702f-706f. Seealso Carpus. x-ray energyrelatedto, 6, 6f
perforation of, 650f
interphalangeal. SeeInterphalangeal joints; Kilovolt peak (kVp)
peristalsisrn, 642, 644f, 645f,654f
pseudoulcersof, 642, 644f Phalanges. contrast relatedto, 15-17, I6f
radiography of, 639-644,640f, 642t, intertarsal,7l6f-719f. Seea/soTarsus. film blacknessrelatedto, l0-11, 10f, 15-17,
613f-646f, 643t metacarpal. SeeMetacarpophalangeal 16f
r o e n t g e ns i g n <r e la te dto , 6 3 9 t joints; Metacarpus. focal spot-film distance(FFD) relatedto, i0-
s e d a t i r ee f f e ctsin , o 4 l metatarsal. SeeMetatarsophalangealjoints; 12, 1If
" s t r i n g o f p e ar l:" e ffe ctin , 6 4 2 ,6 4 4 f Metatarsus. l ow vs. hi gh setti ngfor, t5-1 7, l 6f
" t h u m b p r i n t " a p p e a r a n cein , 6 5 3 , 6 5 5 f, tarcal,7l6f-719f. Seealso Tarsus. x-ray energyrelatedto, 6, 6f
656f ,olnr olsease,16/-zu/ Krrscnnerprn, I/21
u l t r a s o n o g r ap ho! i, 6 4 .16, 4 9 , o 5 If canine/feline Knee. SeeStifle.
vol\nlus oI, Of l-Of,l arthritis in,199-202 Knock-knee (valgus) deformity, equine,
w a i l a 1 rm , b ff,- o ) o polyarthritis as, 200-202, 20irf 24r-242,243f
Intussusception,345-348, 648-649 polyarticular, 199-200, 199f, 200t Klphosis, canine/feline,l0l
canine/feline rheumatoid, 200, 200f
c e c o c o l r co,o / , ob /I septic (infectious), 199-200, 199f, 20Or
colon affectedb,v,648-649, 667,667f SLE causing, 200-20I "I
-r*'
.
g a s t r o e s o p h a ge3a4l.5 - 3 4 8 ,3 4 6 t. 3 4 7 f contrast media technique for, 189, l90f
diaphragm affectedin, 369-371,370f, degenerative,189-190, l9lf, Iglt, I92f. Lamina dura
3 7r f , 3 7tt Seealso Osteoarthritis. cani ne,72,72f,73,75f
esophagusin, 345-348, 346f, 347f, 37It developmental disorders in, 146-160, 1461 hyperparathyroidism affecting, 73, 75f
ileocolic,647f, 648-649,667, 667f fracturesin, 195-196, 196f, l97f Laminitis
small intestineaffectedby, 647f,648-649, hemorrhage causing, 199 equine, 283-286, 284f, 285f
651f hip dysplasiain, 190-195, l93f-195f, I96t "founder" distance in, 284-286, 285f
Iodine preparations,576t, 642t, 643t hypertrophic osteopathy in, 202, 202f prognosisin, 286
in canine/felinepatients neopiasia in, 203f, 204f, 205 radiographic evaluation of, 283-286, 284f,
c y s t o g r a p h iu c s e o f. 5 7 5 - 5 8 1 .5 7 6 f.5 7 6 1 , radiographic signs in, 187-207,187f, t87t, 285f
s82f l 90l 19l t,2001 "ski-tip" appearance tn, 284f
75O I NDE X

Laminitis (Continued) L:ung (Continued) Lymphadenopathy ( Continued)

stagesin, 284 alveolar pattern in, 313-315, 437-440
Laparotomy, 516, 523-525, 526[ differential diagnosis fot, 437-440, 437t,
canine/feline,5 | 6, 523-525, 526f 439f-443f
peritonealgas relatedto, 516, 523-525, 526f diffrrse vs. localized, 437t, 447*440
Larmor frequency, 31 mixed, 440, 44If,443f
Larynx radiographic signs for, 3131
canine/feline, 323-324 anticoagulant affecting, 437, 44lf
a n a t o m i cf a c t o r sa n d, 3 2 3 ,3 2 3 f,3 2 4 1 arteriesand vesselsof, 3ll, 31lf, 315t,
functional abnormalities of, 324 318f,3181
mass lesions of, 323-324 bronchial pattern in, 318, 319f, 431
equine, 451-455,725f calcification in, 431, 43If-433f, 43lt
anatomy of,451,451f differential diagnosis for, 43lt
arytenoepiglottic folds in, 451, 451f,454f, dilatation in, 431, 433f, 439f
46Zf inflammation in, 431, 433f
arytenoid cartilage in, 45I,451f thickening as, 431, 432f, 433f
disordersaffecting, 452-455, 452t-4551 calcified lesions of, 445, 445t, 446f
epiglottic function in, 451452, 45lf-454f edema of, 408-409, 4llf, 412f, 428f, 440f
inflammation of, 452-455, 453f, 455f emphysema of, 440, 443f, 444f
massesaffecting, 452, 452f, 454f end-on vesselsin, 315-316, 315t
mineralization in, 452-455, 453f, 455f heartworm diseasein, 435,435f
paralysis affecting, 461462 hemorrhage affecting, 437440, 44lf
radiographic signs related to, 452-455, hyperlucency of, 436f, 440, 440t, 443f, 444f
452f-45sf differential diagnosis for, 4401
Lead diffrrse vs. focal, 440t
atomic number of, 43t interstitial pattern in, 315-316, 432437
grid construction using, 14-15, l4f, l5f differential diagnosis for, 434t
radiopacityo[, 43f, 43t, 44f diffuse vs. localized, 434t, 435-437,
Legg-CaM-Perthesdisease,149, 15lf 437f-439f
Ligaments str uctured(nodul ar),3l 5-316, 3l 5t,
canine/feline 3 r 6f , 432-43s, 43 4f43 6f , 434t
atlantoaxial, 62f unstructured (hazy), 316, 3I7f, 318t,
joint trauma affecting, 196-199,197f, l98f 434t, 435437, 438f, 439f
s p i n a l ,5 7 , 6 2 f , 1 1 0 -1 1 1 ,1 1 lf mass in, 434t, 435f, 439f, 441f, 445, 445f,
equrne 446f
metacarpal/metatarsal, 25 4-258, 255f-258f mediastinal shift affecting, 440, 44lf
metacarpophalangeal/metatarsophalangeal, neoplasia of, 434t, 435, 435f, 439f, 441f,
259,274f, 275f 445, 445f, 446f
phalangeal,271, 274f, 275f nodules in, 308-310, 3091 315*316, 315t,
Light (visible) 432-435, 434f-43 6f , 434t
intensifring screenphosphorsproducing, 13, l3f cavitary, 315, 3I6f, 434t, 436f
speed(velocity) of, 1, lt noncavitary, 315, 315t, 434t
wavelength of, 1t pneumonia affecting, 437, 439f
Lipidosis, canine/feline, 543, 544f pneumothorax and, 397-398, 397t, 398f-
Lithiasis. SeeCalculi. 400f, 442f, 444f
Liver, 540-549 smoke inhalation affecting, 440, 443f
canine/feline, 54V549 vascularpattern in, 316-318, 318f, 3181
abscessaffecting, 544, 547f, 548f, 549t equine, 463-475
anatomy of, 483484,485f, 540-541, 540f- abscessin, 469470, 471f, 472f, 479f
542f allergic effects in, 474
decreasedsize of, 484, 543-544,544r,546f, collapse/rupture of, 472, 473f
547f edema of, 472-473
enlargement of, 495, 497f, 541-543, 542f- emphysema affecting, 473, 474f
546f, 5431 hemorrhage in, 470, 473f
gas tn, 544, 547f mass in, 468, 469f
gastric axis related to, 540-543,540f,542f, neoplasia of, 474
544, 546f normal appearance of, 463, 464f-467f
inflammation of, 543, 545f obstructivediseaseof, 473,474f
lipidosis affecting, 543, 544f pneumonia affecting, 469, 469f472f
massesassociatedwith, 495-496, 498f-- pneumothorax and, 472, 473f, 478, 479f
500f, 5491 radiographic technique for examination of,
neoplasiaof,543,543t 463, 464f-468f, 468-469
normal, 540-541, 540f-542f vascular dysfunction affecting, 472
shapeof, 543,544f Lymph nodes, 529-531
stomach displacement by, a85f, 543-544, canine/feline
545f, s46f abdominal, 484, 529-531
ultrasonography of, 540-549, 541f, 542f, parietal vs. visceral, 484, 529-531, 529f-
s44f, 545f, 548f, s48t, 549t s32f
Lordosis, canine/feline, 101 u lr rasonography oi 531, 53If, 532f
Lumbosacral joint barium uptake by, 445, 446f
canine/feline,101-102, 102f, 123 peritoneal, 529-53l, 529f-532f
degenerativeabnormalities of, 101-102, 102f, retroperitoneal, 529-53L, 529f, 530f
t23 tracheobronchial, 445, 446f
Lung Lyrnphadenopathy
canine/feline, 3 10-320, 43 1449 canine/feline
abscessin, 436 abdominal, 529-53I, 529f, 530f, 532f
colic, 496,506f
i l i ac, 513, 513f,s29,529f,530f
mediastinal, 38 1-383, 382r, 383f-385f,
3831
mesenteric, 530f
equrne
guttural pouches with, 455, 456f
parapharyngeal, 455, 456f
Lymphosarcoma
cani ne,513, 5l 3f
feline, 506f
Lysosomal storage disease,73
"Mach band" effect
boundary enhancementby, 35,36f,248, 248f
false fracture lines due to, 35, 36f, 248,248f
metacarpal/metatarsal, 248, 248f
optics of, 35, 36f
Magnetic resonanceimaging (MRI), 29-34
basic physics and principles of,29-34, 30f-
34f, 3rt,32t
encoding gradients in, 32-33, 33f
intensity factors in, 32-34, 321,33f, 34f
proton spin in, 29-31, 30f
radiofrequency pulse sequencein, 29-34, 30f,
3Zf,33f
relaxation times in, 3l-34
T1, 31, 311,32f-34f,32t
TZ, 3t-34, 31r, 32f-34f, 32r
tissue factors in, 3I-34, 3lt, 32t
Mandible, 65f-68f,70f
canine, 65f-68f, 66, 70f, 72f, 75f, 76f, 83f, 84f
anatomy of,693f,694f
craniomandibular osteopathy affecting,
83-84, 83f
neopl asi aof,76,76f
teeth in, 72, 72f, 72t, 84f, 693f, 694f
equine, 66, 67f, 725f, 726f
feline, 75f, 76f, 82f, 83f, 86f
teethi n, 72,72f,72t,82f, 83f, 86f
Mastocytosis, equine phalangeal, 290
Maxilla
canine, 65f, 66f, 72f, 73f, 75f, 78f-80f, 83f
anatomy of, 689f-691f
neopl asi aof,76,76f
teeth in, 689f-69 | f , 693f
equine, 67f, 90f, 9lf,725f,726f
teethi n, 725f,726f
feline, 81f-83f, 86f
Mediastinum, 376-389
canine/feline
anatomy of, 376-380, 376f-37 9f
disorders affecting, 380-389, 380f-389f
fluid in, 383, 386f
gas in, 383-388, 387f,388f
lymphadenopathy in, 381-383, 382t, 383f-
385f, 383t
massesin, 380-383, 38lf-385f, 382t,383t
neoplasiaof, 381-383, 381f, 3821,383f-
3851 3831
normal, 376-380, 376f-380f
obesity and, 377, 379f, 380f
organs included in, 376f, 377t
pleural effusion effects and, 381,382f
shift affecting, 380, 380f, 440,44lf
sunoueftrngana, 5/ /-t/6, t/ /T
thorax evaluation role of, 3ll-3l2,312f,
313f,377f-380f
Megacolon, 665
canine/feline, 665, 665f, 666f
Megaesophagus
canine/feline, 335-336, 337f, 338f
foreign bodies causing,J35-336, J37f, 338f
 INDEX 75I

Melanoma, canine/feline,subungual,182-184' Metatarsus, 247-259 Nasal passages(Continued)

r84f equ.ine,247-259 fl ui d col l ecti oni n, 89, 90f, 9 4f,96f,97,97f
Meninges, myelomeningocele of, lZ4 anatomy of, 247-248, 247f, 248f, 7 I6f-7 19f foreign body in, 91, 9lf, 92f
M en i n g r o m a ,/ / , / 6 I b o ne l ysi si n,25l ,25l f fracture affecting,89-91, 901 9if
canine/feiine, 77, 78f, 124 fracture affecling, 251-254, 251f-255f hematoma in,94,96f
nerve root affected by, 124 ligamentsand tendons of, 254-258, 255[- i nfl ammati onn, 90t, 96f, 97 . 97f
Mesaticephalic shape,66-67 , 71, 72f 258f neoplasia affecting, 91-97, 92f-97 f
Mesentery mineralization affecting, 249, 249f radiographic abnormalities of, 89-98, 90t-
canine/feline, 496, 505f, 506f periosteal responseaffecting, 249, 249f- 98f
massesassociatedwith, 496, 505f, 506f 25l f tooth abscessaffecting, 96f, 97, 97f
Metacarpophalangealjoints scintigraphy of, 251, 255f Nasal septum, 71
canineifeline,19lf soft-tissue lesions of, 248-249, 249f, 25lf canine/feline, 65f, 66f, 7 l
sesamoidbones of, 1881,189, 19lf splint bones of,247-248, 248f equine, 67f, 89, 89f
eqtine,259-269 ultrasonography of, 254-258, 255f-258f deviation affecting, 93f, 94, 95f
anatomy of, 259, 272f, 274f, 275f, 708f' Mice, joint with, 146, 187f, 188, 1881 Nasal sinuses,Seealso Nasal passages.
7 11f-7 15f Microcardia,419 canine/feline,7l-83
bone lysis in, 262, 262f, 267f canine/feline,419 equine, 87-98, 90f, 96f, 97, 97f
cortisone arthroPathy of, 262-263, 263f Addison'sdiseasein, 418f, 419 National Council on Radiation Protection
disuseatrophy in, 267, 267f hlpovoiemia in, 419 (NCRP), 3
effusionsof,260 Microhepatia, 543-544 Navicular bone, 295-305
fracturesaffecting,265-267, 265f, 266f canine/feline, 484, 543-544, 5441,546f, 547f equine, 295-305, 708f-7 10f
infection of, 264-265, 265f differential diagnosis in, 543-544, 544t analgesiaof,297
l i g a m e n t sa n d t e n d o n so f, 2 5 9 ,2 7 4 f,2 7 5 f portosystemic shunt causing, 543-544, anatomy of, 295, 295f, 708f-7 llf
MRI of, 260,261f 546f,547f degenerativesigns in, 297-301, 298t, 299f-
osteoarthritis of, 262, 262f, 263f Microwaves, lt 301f
osteochondrosisof, 263-264, 263f, 264f fractures affecting, 301-302, 302f, 303f
Milliampere seconds (mAs)
radiographic technique for examination of, infections of, 302-303, 303f
contrast relatedto, l5-I7' l6f
259-260 navicular syndrome and, 297-301, 298t,
film blacknessrelatedto, 10-11, 10f, 15-16,
s e s a m o i d i t iisn , 2 6 1 f, 2 6 6 f,2 6 7 299f-301f
16f
soft-tissue swelling in, 260,265f, 268f osteoarthritis of, 303-304
focal spot-film distance (FFD) related to, 10-
villonodular synovitis in, 260-262, 261f, radiographic technique for examination of,
12, l Of, l l f
262f 295-297, 296f, 296r, 297f
low vs. high setting for, 15-I7, I6f
Metacarpus Necrosis, aseptic
radiation quantity and, 7, 7t
canine/feline, 680f-682f canine/feline,149, 151f
Mitral insufficiency, 404f, 414415
equine,247-259 femoral head affected by, 149, Islf
Monteggia fractures, canine/feline, 163
anatomy of, 247-248, 247f, 248f, 702f- Neoplasia
M o r g a ns l i ne, 191, 193f
7 0 7 f , 7 r l f - 7 r5 f canine/feline
Motion/movement, radiographic effects of, 12
b o n e l y s l sl n ) l ) l ' z) lr bone affected by, 179-186, I79f-181f,
Mucopolysaccharidosis,73
fracture affecting, 251-254, Z5lf-255f 183f-185f
canine/feline,153-154, 155f
ligaments and tendons of, 254-258, 255f- colon affected by, 667, 669-670, 669f
bone changesdue to, 73, 103
258f esophaguswith, 336, 338f-340f
facial dysmorphia in, 153
mineralization affecting, 249, 249f femur with, 180f, 183f
feline in, 73, 103 fracture complicated by, 176, 176f
periostealresponseaffecting,249' 249f- vertebrae affected by, 103 joints affected by,203f, 204f, 205
2.5 TI
Multiple cartilaginous exostosesr104-105, kidney affected by, 498, 507f-509f, 560f
scintigraphyof, 251, 255f 156-157, L57f
soft-tissue lesions of, 248-249, 249f, 25lf liver affected by, 543, 543t
Multiple myeloma, vertebral, 105, 106f lung affected by, 434t, 435, 435f, 439f,
splint bones of, 247-248, 248f Muscle, radiopacity due ro, 43-44, 43t
ultrasonography of, 254-258, 255f-258f 44tf, 445, 445f
Muscular dystrophy, canine/feline diaphragm mandible with,76,76f
Metal
in ,371-373 max[la wrtn, /o, /or
atomic number of, 4344,43f,43t, 44f
Mycoses,canine/feline lung with, 437, 438f mediastinum in, 381-383, 381f, 3821,
radiopacity due to, 43-44, 43f,43t,44f
Myelography,|L4-I25, 128 383f-38sf, 3831
Metaphyses,135-137, I36f
in canine/felinepatients, ll4-125, I l5f-123f, nasalpassages affectedby, 73-76,75f
canine/feline,).35-137,l36f
i16t, 1201 ovaries with, 498, 510f, 608-609, 609f
b l o o d s u p p l y t o , 1 6 7 , l6 7 f
artifactsin, 116, 119f peritoneal spacewith, 518, 520f, 523,52Jt,
d y s p l a s r aasf f e c t in g .1 5 5 - 1 5 8 'l5 5 f' l5 7 f
"canalogram"in, 116-120, 119f 525f
f r a c t u r e sa f f e c t i n g ,1 6 3 , l6 3 f
hypertrophic osteodystrophy of, 152-153' diagnosticpatternsseenin, 116-123, 116t, pharynx with, 323-324, 324f
1) J I
rr7f-r23f, r20t ribs affected by, 351-357, 356f, 358f
Metatarsophalangealjoints, 259-269 interpretiveprinciples for, l16-123, ll6t, skull affected by, 73-77, 75f-7 8f
equine,259-269 rrTf-123f, l20r small intestinewith, 652-055, 653f, 655f'
anatomy of, 259, 274f, 275f techniquefor, ll4-116, 115f, ll6f 656f
bone lysis in, 262, 262f, 267f in equine patients, 128, l28f spinal cord affected by, 124
cortisonearthropathy of, 262-263, 263f technique for, 128 stomach affected by, 629-631, 629f, 630f
disuseatrophy in, 26:. 267f Myelomalacia, 119f subungualmelanoma as, 182-184, l84f
effusions of, 260 Myelomeningocele, 124 urethra affected by, 589f, 590f
fracturesaffecting,265-261. 265[, 266f urinary bladder with,577,580t, 58If, 585-
-q- s86, 585f
infection of, 264-265, 265f :B$*
l i g a m e n t :a n d t e n d o n so l, 2 5 9 ,2 7 4 f,2 7 5 t
I ---d vertebrae affected by, 104-105, i06f, 107f
M R I o l 2 6 0 , 2 6 1f Nasal passages,7 l-86, 87-98 equine
osteoarthritisof,262, 2621.263f canine/feline, 71-86 lung affected by 474
osteochondrosis of, 263-264, 263f, 264f anatomy of , 7 1, 72f, 689f-692f nasalpassages affectedby, 9l-97,92f-97f
radiographic technique for examination of, foreign body in, 78, 80f Nephrocalcinosis, canine/feline, 561
2s9-260 infections of, 77-7 8, 79f Nephrography, in canine/feiine patients, 556,
sesamoiditisin, 263f, 266f, 267 neoplasia affecting, 73-7 6, 75f ss8-s60, 560f, 562r, 565f
soft-tissue swelling in, 260, 265f equine, 87-98, 725f, 726f Newe roots, 11lf
villonodular synovitis in, 26V262, 26lf' anatomy of, 87-89,88f, 89f, 725f, 726f canine/feline, 110-1 11, llzf, 124
262f cyst of, 9l-94, 93f-95f,97 neoplasia of, 124
75.2 INDEX
Net magnetization vector, 30, 30f
Neurofibroma, 124
canine/feline
nerve root with, 124
vertebrae affected by, 105, 106f
Neutron radiation, dose from, 3
Nipples, 48f,352f
canine
artifact due to,46,48f
enlargement of, 487
thoracic wall appearancedue to, 350, 352f
Nuclear Regulatory Commission (NRC), 3
Nucleus
gamma rays emitted from, I
MRI role of,29-31, 3Af
Nucleus pulposus, 110-i11
ana t o m yo f , 1 1 0 ,l 1 l f
ex t r u s i o no f , I I 0 - l l I , I l3 f
fibroid degenerationof, 111
Obesity,379f,380f,5l7f
canine/feline
a D d o m e nl n , ) 1 b , ) r ,/r
mediastinum in, 377, 379f, 380f
radiopacity role of, 43-44, 43f, $r, 44f
Occipital bone, canine, 690f
Occipitoatlantoaxial malformatio n, 128-129
equine,128-129, l29f
OFA method, hip distraction using, 195, 195f,
t96r
Olecranon
canine,678f-680f
eqrine, 720f, 72lf
Optical illusions, 35-41
errors/distortions due to, 35-41, 35f4ll 47, 49f
interpretations affected by, 35-41, 35f4Lf,
47,49f
Ortolani's sign, 191
O s pe n i s ,c a n i n e , 7 0 1 f
Ossification
end o c h o n d r a l1, 3 5 - I 3 7 , l3 6 f
humeral incomplete, 157-158, 157f
intramembranous,137
Osteitis, equine phalangeal, 281, 28If, 282f, 288
Osteoarthritis
canine/feline,189-190
enthesophltesin, 189-190, l92f
hip dysplasia role in, 189
osteophytesin, 189-190, l92f
primary vs. secondary, 189
signs in, 189-190, l9lf, l9k, l92f
equine
carpus in, 244-245, 244f, 245f
metacarpophalangeal/metatarsophalangeal,
262,262f,263f
navicular bone in, 303-304
phalangeal, 282-283, 283f
stifle in, 220f
tarsusln, zzt, zz+r
Osteoarthrosis,equine interphalangeal, 283f
Osteochondraldysplasia,I 55-158' l55f-157f
Osteochondritis dissecans,146-147, 147f, l48f
Osteochondroma, 202--205
canine/feline, 188t, 202-205, 203f
synovial, 188t, 202-205, 203f
Osteochondrosarcoma,canine, 76-77, 77f
Osteochondrosis
canine/feline, 146-147, 147f, l48f
equrne
carpuswith, 238-241, 241f,242f
metacarpal/metatarsal,263-264, 263f, 264f
phalangeal, 287-288, 289f
stifle in, 216,2I8f
tarsus in, 222-223, 223f, 224f
Osteoclasts,l35
osteopetrosisrole of, 154-155, l54f
Osteocytes,135
Osteodystrophp I 52-l 53
canine/feline, 73, 103, 139, 152-153
hyperparathyroidism causing, 73, 7 5f, lO3,
104f
hypertrophic, 139, 139f, 152-153, l53f
vertebrae affected by, 103, l04f
Osteogenesisimperfecta, collagen role in, 154
135,IJTf
Oste o id ,cani ne/fel i ne,
Osteolysis, 135, 137-139, I37 f-139f, l4lf
equine stifle affected b5 2Il,2l2f
g e o g r a phi c,138,138f, l 4l f
moth-eaten, 138, 138f, l41f
p e r m e a ti ve,138, 139f,141f
usteoma, canrne,/ /, /6r
Osteomyelitis
canine/feline
bacterial,182, 182f, 184f
fracture complicatedby, 172-173, 174f,
r82f
hematogenousspreadof, 182, 183f
metaphyseal-epiphyseal,181f
mycotic, 179-182, 181f, 183f
open fracture with, 182f
tumors differentiated from, 179-186
vertebrae affected b5 104, 105f
equine
metacarpophalangeal, 2I1 , 2I2f
phalangeal, 281,28lf
stifle in, 218-219,220f
tarsusin, 225f' 226, 226f
vertebrae affected by, \29, I30f
Osteopathy (hypertrophic)
canine/feline,139, 140f, 202, z\Zf
equine, 290
Osteopetrosis,canine/feline,103-104, 154-155,
r54f
Osteophytes
canine/feline, 141, 143f, I87, I87f
acetabulum with, 193f, 194f
femur with, 151f, 191, I92f-194f
osteochondritis with, 148f
radiographic evaluation of, I4I,143f, l87f
radius with, 150f, I92f
tibia with, 148f, I92f
ulna with, 150f, l92f
equine
carpus affected by, 244-245, 244f, 245f
stifle affected by,220f
Osteoporosis, canine/feline senile, 103
Osteosarcoma, I79, I79f-I8lf
canine/feline
fixation deviceassociatedwith, I76, 176f
fracture complicated by, 176, 176f, 179
periosteal reactions due to, 179, l79f-l8lf
Otitis, 78-80, 80f-82f, 86f
canine/feline, 78-80, 80f-82f, 86f
ear canal neoplasia causing, 80, 82f
nasopharyngealpoiyps causing, 80, 82f
radiographic appearanceof, 78-80, 80f-82f
t)'rnpanic bulia in, 78-80, 80f-82f
Ovaries,607-610,614
canine/feline, 607-610, 614
anatomy of, 487
cyst of, 609, 609f
imaging technique for, 607, 609f
massin, 498, 510f, 608-609, 609f
neoplasiaof, 498, 510f, 608-609, 609f
normal, 607-608, 609f
Palatine fissure, 691f
Pancreas,485f
canine/feline
Pancreas(Continued)
abscessof, 524f
anatomy of,485f,487
inflammation of,521f, 522, 524f
massesassociatedwith, 496, 506f
Pancreatitis
canl ne/Iel rne, Jl rt, Jzz, Jz4l
peritoneal spaceaffected by, 521f, 522, 524f
Panosteitis, 152, l52f
cantne/re[ne,r5z\ r>Ll
Paranasalsinuses.SeeNasal passages.
Parasitism. Seealso Heartworm disease.
ascarid,648, 650f
small intestine with, 648, 650f
Parathyroid hormone, 73, 137
canine/feline
bone metabolism affected by, 73, 137
excessive.SeeHyperparathyroidism.
skull changesdue to, 73, 75f
Pasteurellainfections, nasal, 78, 79f
Patella
canlne
anatomy of, 684f-686f
fat body of, r87, r99f, 203f, 685f
equine,215, 2l6f-218f
anatomyof,721f,722f
fracture affecting, 219, 220f
normal ,215,2l 6f-218f
Patent ductus arteriosus, 3llf, 405f, 419
Pelvis
canine, 683f, 684f
eqrine,723f
PennHIP method, I95, I95f,196t
Pennies,zinc toxicity due to, 645
Penumbra
edge unsharpnesswith, 12, 12f
focal spot size related to,12, I2f
Perception. SeeVisual perception (human).
Pericardial effrrsion, canine/feline, 417, 418f,
419
Periodontal disease,84, 97
canine/feline,84,84f
equine, 96f, 97, 97f
Periodontal membrane, 72, 72f
Periosteum,138-141
canine/feline, 167, 167f, 179, 179f-l8lf
blood supply to,167, l67f
new bone reaction of, 138-141, I39f-l4lf
osteosarcomaand, 179, 179f-l8lf
equine
inflammation of, 249, 249f
metacarpal/metatarsal, 249, 249f
Peristalsis
canine/feline, 642, 644f, 645f, 654f
small intestine with, 642, 644f, 645f, 654f
rerltoneat ilulo, 5rb-5_t6
canl ne/rel tne. 5 l b-) Id. ) Idt-)z3r
abscessand, 520f-522f, 524f
opacity due to, 516-518, 5l8f-523f
pleural fluid wirh,397
ultrasonographyof, 518-523, 52lf-523f
urinary bladder obscured by, 572, 573f
Peritoneal space,516-539
canine/feline
abdominal wali defects affecting, 525-528,
528f
abscessaffecting, 520f-522f
cal crne(lD odresl n, 525,5z5l
fluid opacity in, 516-518, 5l8f-523f
gas accumulation in, 523-528, 526f-528f
inflammation affecting, 518, 520f-522f
l1nnph nodes of, 529-53I, 529f-532f
neopl asi aof, 518, 520f, 523,5 23f,525f
trauma affecting,518, 519f, 527f,528,528f
ultrasonographyof, 5 | 8-523, 521f-524t
Peritonitis
abdominal effects of, 518, 520f-522f
 INDEX 75,3

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

Radirs (Continued) Scattering (Continued)

Radiation. Seealso X-taYs.
eqrine, 702f-706f radiation subject to, 9-10, 9f
absorption efficiencyfor, 2-3, 2f, 4244, 42f-
anatomy of,702f-706f Scoliosis,canine/feline, 101
44f
Radon gas, 4 Sesamoidbones
basic properties of, l, It,2f,2t
radiation exPosuredue to, 4, 4f canine/feline
biologic matter interactions of, 1-5, 2f, 8-10'
Rare-earthPhosPhors'13, l3f anatomic locations of, 1881, 189
9f joint diseaserole of, 188t, 189, 191f
"braking," 5-6,6f Rectification, of electric current, 6, 7f
Rectum, 660-662 equrne,/l II-/r)r
bremsstrahlung, 5
canine/feline inflammation of, 263f, 266f, 267
"characteristic," 5, 6f, 9f
anatomy of, 660-662, 661f, 662f, 666f metacarpophalangeal/metatarsophalangeal,
cosmic, 4, 4f
displacement of, 593, 593f, 662f, 666f 263f,266f,267
dosagesof, in familiar activities, 4, 4f
prostate enlargement affecting, 593, 593f, Sharpey'sfibers, 102
electromagneticnature of, l, lL 2f,2r canine, 102, 103f
exposure limits for, 2-4, 4f 666t
Rem unit, 2-3 spondylosis role of, 102, 103f
ionization caused by, 1, 2f, 3 Shoulder, 1421
physicsof, l, lt,2f Remodeling, bone, 136-137, l36f
canine/feline
protection factors and, l-5' 2f' 4f Retroperitoneal sPace'516
anatomy of, 142t, 676f, 677f
rado n , 4 , 4 f canine/feline
osteochondrosisaffecting, 146-147, 147f
safety factors related to, l-5,2f' 4f definition of, 5t6
sesamoidbones of, 1881,189
scattered,9-10, 9f flu id in, 516-s18's19f
equrne, /zur
film affected bY, 14-15, 14f, 15f gas in, 383-388, 388f,527f
anatomy of,720f
grid absorption of, l4-i5' 14f, i5f hemorrhagein, 518, 5i9f
Shunts, 543-544,621
sources of, in U.S., 3-4, 4f' 4t lymph nodes of, 529-531, 529f, 530f
portosystemic, 543-544, 546f, 547f
units of, 2-4 massesassociatedwith' 498' 507f' 509f
scintigraphy of, 491f, 492
wavelength of, I, lt,2f "ReverseD" sign, cardiac, 406, 406f
small liver d're Io, 62I, 6z2f
Radiographs,l0-17 Rhinitis, 77-78,79f
stomach displacement related to, 621,622f
basic procedures for making of, 10f-16f' 10- canine/feline
Sidebones,equine phalangeal, 288, 289f
17, l7t infection cawing, 77-7 8, 79f
Sievert(Sv) unit,3
blackness/opacity of, 10-12, 10f' 1lf, l4f' 16- IymphoPlasmacYtic' 77-7 I
"Silhouette" sign, radiographs with, 46, 48f
17, r6f, 4244, 4zf-44f , 43t equine, 89, 90f
Silver halide crystals
border effacement sign in, 46, 48f Ribs, 57, 58f,35r-357 film emulsion with, 10, 12, l2f
collimator use for, 10, IOf canine/feline,57, 58f' 350f-352f, 351-357 sl.zeoI, 12, lzr
common technical errors affecting, 17, l7t' costochondralmineralization in, 350, 35if Sinusitis
18f, 45, 45f exostosesaffecting, 156-157' 157f clinical signs in, 97
contrast factors for, 15-17 I6f, 46' 48f fracturesaffecting,35I' 353f-355f equine, 90f, 96f, 97, 97f
' infection related to, 357' 357f-359f
darkroom processing of, 17 Situs inversus, canine/feline, 414, 4l5f
depth perception loss in, 45, 46f normal radiographic appearance of' 349' Skeleton. Seealso specific structures and
film exposure factors and, 10-17, 10f-16f' 350, 350f-353f disorders.
r7t, 42-44, 43f tumors of, 35I-357,356f' 358f appendicular. See alsoBonei Joint(s); Joint
grids used for, lal-15, 14f' 15f vertebral anomalies affecting, 99-100' 99f' disease;specifc bone or joint.
image detail factors for, 12-15' l2f-15f,42- 101 canine/feline, 135-207
46, 42f-49f equme, )./, )dr developmental disorders affecting' 146-
intensifring screen fo6 I3-I4, L3f Ripple factor, x-rays affected by, 8' 8f 160, 1461
interpretation of, 35-56 Rodenticide toxicitY fractures affecting. SeeFractures, canine/
abnormalities evaluation approach in' 5l- anticoagulant role in, 437, 44lf feline.
5 3 ,5 2 f , 5 3 f canine/feline lung affected by, 437, 44If interpretation paradigms for, 135-i45,
errors relatedto, 35-41, 35f-4If,53 Roentgenunit,2-3 r36f-r4lf, r42t, 143f, r44f
experience and understanding in, 47-51' Rugal folds, canine/feline stomach with' 617, joint diseasein. See|oint disease.
s O f ,s i f 6 2 0 f, 63rf tumor vs. infection in, 179-186
role of perception in, 35-41, 35f-41f, 47- equine, 209-305
51, 49f alternate imaging for, 2lI-214, 2l3f
twelve-step process for, 53-56' 55f anatomic overview and, 210-2ll' 2l0f
projection/view naming system used in' 47' Saccadiceye movements (human), 39-4l,4lf interpretation paradigms for' 209-214,
49f Sacroiliac joint, canine' 683f, 698f 2r0f,2r2f,2r3f
reading methods for, 35-41, 35f4lf, 5I-56 Sacrum radiographictechnique and' 209-2lt'
silhouettesign in, 46, 48f canine, 58f, 683f 2r0f
summation shadow effect in,45' 47f equine, 58f aial. Seealso Skuli; Spine; Vertebra.
unfamiliar image in, 45, 46f Safety factors, 2-5 canine/feline, 57 45, 58f-65f, 70f' 98-109
visual perception related to, 35-41, 35f4If, aprons, gloves, gogglesin' 4' 5 equine, 57, 58f, 59f, 63,63f,127-133
47, 49f basic rules foq 5 Skin-fold artifact
Radiopacity, 43-44, 43t, 44f monitoring in, 4-5 canine/feline, 399401, 40If
fat and, 4344, 43f, 43t' 44f personnel use of, 4-5 pneumothorax vs., 399-401, 40lf
radiation-related, l-5, 2f, 4f "Ski-tip" appearance,equine hoof with, 284f
fluids with, 43t, 44
shielding in, 4, 5 Skull, 65-98. Seealso Cranium; Nasal passages;
thickness affecting, 43f,44' 44f
"Sail" sign, 312,3l3f Teeth.
tissue factors Ln,43-44,43t' 44f
Salter fractures, canine/feline, 163, l63f' l64f canine/feline, 65-86
Radio waves, lt
Sarcoma,176,205 anatomy of, 65-69, 65f-67f, 689f-694f
Radius
canine/feline bony proliferation affecting, 83-84' 83f
canine/feline
fracture complicatedbY, 176, I76f brachycephalic,66-67 , 7 |
anatomy of' 678f-682f
joint affected bY,203f' 204f' 205 congenital anomalies affecting, 72-73' 72f-
fractures of, I64f-166f, 172f, l73f' l76f-
178f synovial, 203f, 204f, 205 /Jl

Scapula craniomandibular osteopathy affecting,

hypertrophic osteodystrophy of' 152-153,
canrne,b/or, o/ /r 83-84, 83f
I 53f
equme, ,/zur CT scan of, 68f, 69,70f
infarction of, 180f
Scattering feline in, 75f, 76f, 78f,79f,8lf-83f, 86f
infection of, 183f, f84f
coherent, 9 infectious disorders related to, 77-81' 79f-
panosteitis affecting, I52' I52f
Compton, 9-10,9f 82f
tumor of, 179f, 180f
 INDEX 755

Skdl (Continued) Spine (Continued) StiIIe (Continued)

interpretation paradigms fot, 67-69
MRI ol 68f, 69, 70f
neoplasiaaffecting, 73-77, 75f-7 8t
occipitaf dysplasiaof. 72-73, 73f
radiographictechnique for, 65-67, 65f-67t
scintigraphy of, 69, 70f
s h a p ev a r i a t j o n so f. 6 6 - 6 7 ,7 1 ,7 2 f
traumatic injury affecting,8l-83, 83f
ultrasonography of, 69, 69f
equine, 65-69, 67f, 68f, 87-98
anatomy of, 65-69, 67f, 68f,725f,726f
C T s c a no f , 6 8 f , 69
nasal passages of, 87-98
radiographic technique for examination of,
67f, 68f, 87
SLE (systemiclupus erythematosus),200-201
arthritis due to, 200-20i
clinical manifestationsof, 200
Smoke inhalation
canine/feline,140, 443f
lung affectedbv, 440, 443f
Soft palate
c a n i n e ,6 8 9 1 6 9 2 f
e n r r i n e4. i I - { i 2 . 1 5 1f4 ) 3 t, 7 2 5 f
rr dr- - - - . . . dlr
- rur r : 1 r:) r q l[_ 4 5 3 f
lr l^
pharynx and, 455456, 457f
Sole,equine, 708f-710f
Sonography.SeeUltrasonography.
Sound waves,basic physicsof, 20-22,20f
Spina bifida, canine/feline,99-100, l00f
Spinal cord
canrne/Ielrne,I I Ir, I ll,r
anatomy and, 110-111, 11\f, IIzf, II7f,
rrgf, l21f
arachnoid cyst affecting,125, l25f
cavitary diseaseof, 124
d i s c p r o t r u s i o na ffe ctin g 1
124, 120t, l2lf-]l23f
f e l i n ei n , 1 l 7 f
fibrocartilaginousembolism oi-, I14
h o u r g l a s sa P p e a r a n ce in . llll' ll- r ' Il3 i
MRI of, 6af, 65
m v e l o g r a p h vo f . Il+ _ ll5 . I I5 t- l:- r i. I lb t.
i 201
neoplasiaoi 12-{
s e g m e n tn u m b e rin gtb r . ll0
e q u i n e ,1 2 8 , 1 2 8 f
m v e l o g r a p h vo t . l 1 8 . ll8 i
Spinal nerr-eroots, I l0-l I l, I tlf
Sp i n e ,5 7 - 6 5 , 9 8 - 1 0 9 , Il;- 1 3 3 . Se ea lso
\/ertebrae.
a n a t o m vo f , 5 . . 5 8 f- 6 1 f,c8 9 q
canlne
anatomv oi, 57-42,58f--62f,98-99, 683f
cervical,)8f, 694f, 695f
disorders affecting, 99-109, I 10-127
lumbar, 58f, 683f, 696f, 697f
myelography of, rr4-r25, ll5f-123f, ll6t,
t20r
radiographic technique for examination of,
57-63, 62f, 63f-6sf, 99, 99f
sacral,58i 6831 698f
thoracic, 58f, 695f, 696f
cervical, 57, 58f, 59f,98-99, 129-133, 694f,
695f
myelography of, lI4-125, II6t,11,7f, l20t radiographic technique for examination of,
radiographic technique for radiography oi 215-216,2r8f
57-63,99. e9t, ttTt sepsisof, 218-219, 220f
Iigaments of, 57, 62f, ll0-11 1, lllf trauma to, 219,220f
lumbar, 57, 58f, 60f, 6lf, 63f,98-99, 683f, tumoral calcinosisof, 221, 22If
696f, 697f Jromacn, br)-ojr
MRI of, 64f, 65 canine/feline,6 15-631, 616f, 620f, 633-438
radiographic imaging of, 57-64, 62f-64f anatomy of, 4851 486f, 487488,488f,
myelographic, ll3f-L23f, ll4-125, 128 615, 6rsf-62rf
sacral,57, 58f, 6lf, 98-99, 683f, 698f axi s of, 540i 542f,546f,615,616f
scintigraphy of, 64f, 65 calcification affecting, 631, 63lf
thoracic, 57, 58f, 60f42f, 98-99, 130f, 695f- di spl acement of, 620f. 621,622f
697f hepatic, 485f, 543-544, 545f, 546f, 620f,
Sprnousprocess,)Yt, rrlr 62r, 622f
Spleen,549-553 pancreatic,621,622f
canine/feline distention of
anatomy of, 484, 485f, 486f, 549, 550f fluid-filled, 623, 625f, 627f
enlargement of, 496, 50if, 549-553,54%, gaseous,623, 625f-627f
55rf,552f emptying of, 617-618
massesassociatedwith, 496, 502f,503f, delayed,626-628,628f
549,55fi forei gnbodi esi n, 157f,621 423,623f,
nodules in, 549-553, 55lf 624f
torsion of, 496, 504f, 552f, 553 gas/fluidin, 487-488, 488f, 616417, 617f-
Splenicvein, 552f,553 619f
Splenomegaly,549-553 inflammation of, 629f, 631, 63lf
canine/feline, 496, 50fi, 549-553, 549t, 55lf, intussusception affecting
J' ZI diaphragm in, 369-37 l , 370f, 37rf, 37lt
barbiturate role in, 549, 551f esophagusin, 345-348, 346f, 347f
causesof, 549,5491 liver imaging role of, 540-543, 540f, 542f,
differential diagnosis inf, 549, 5491,551f, 545, 546f
55Zr neoplasia of, 629-631, 629f, 630f
generalizedvs. focal, 549,549t,55If, 552f normal appearanceof, 615-618, 6l6f-621f,
Splint bones, equine, 247-248, 248f, 250f 620
Spondylitis,organismsin, 104, l05f organs displaced by, a93, 493f, 625f, 626
Spondylopathy, canine/feline cervical, 101 patient position affecting, 488, 616-617,
Spondylosis 617f-620f
, 1 0 - lll, 1 2 0 - canine/feline,101-103, 102f, l03f peristalsisin, 617-618, 628,628f
deformansform of, 102-103, 103f pyloric obstruction affecting, 624f, 626-
lu mbosacral101-103,
, 1021 103f 628, 627f-629f
myelographyof, I22f review questions on, 633, 634f-638f
stenosi si n, 101-102,102f,103f rocks in, 157f,621-623
e q u ine,l 29 rugal folds of, 617, 620f, 63lf
acquired, 129 ulcer of, 628-629,629f
Sp r a in s ultrasonographyof, 620, 62lf, 630f
ca n ine/fel i ne,196-199,197f,198f vohrrlus of , 623-626, 625f-627f
jo int affectedby, 19G199, 197f,l 98f wall thickrress of,629-631, 631f
stressradiographytechniquefor, 196-199, Stones.SeeCalculi.
r97f, r98f Stressradiography
equine, 276 canine/feline,196-199, 197f, I98f
phalangeal,2T6 joint examinationusing, 1.96-199,197f,l98f
Squamouscell carcinoma techniquefor, 19G-199,197f, I98f
canineifeline,182-184, 185f "String of pearls" effect,duodenal,642, 644f
digital, 182-184, 185f "String" sign, pyloric, 628
"Step deformity" "Stripe" sign, tracheal,326, 326f, 343f
canine/feline, 169, 170f S ubarachnoi space,
d l 1l , 11l f, I l 2f
fracture followed by, 169, l70f arachnoid cyst affecting, 125, l25f
Sternum, 357 contrast media injected into, 114-116, 128
canine/feline in canine/felinepatients,ll4-116, 1l6f-
lnlecilons or, ,)/, J)vr r22f
tumors oI, J)./ in equine patients, 128, I28f
Stifle, l42t Subdural space,11lf, 112f
canine/feline, l42t "summation shadow" effect, radiographs with,
anatomy of, 685i 686f 45, 47f
normal, 143f, 190f, 685f Swallowing disorders, 331-335
patellarfat body and, 187,199f,203f,685f canlne/Iellne, 5 5 l-5 5>, JJJt-JJbr

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
Synovium (Continued)
osteochondroma of, 188t, 203f
radiographic signs related to, 200-205,
200f, 200t, 203f, 204f
sarcoma of, 203f, 204f, 205
equine,260-262
inflammation of
metacarpal/metatarsal, 260-262, 261f,
262f
villonodular, 260-262, 261f, 262f
Syringomyelia, canine/feline, 124
Systemiclupus erlthematosus (SLE), 200-201
canine/feline
arthritis due to, 200-201
clinical manifestations of, 200
Tail
canine/feline,58f
hemivertebrae in, 100
kinked, 100
equine, 58f
Talus, 196f
canine/feline,196f
fractures of, l96f
osteochondritis of, 146-147, l48f
Tarsocrural joint, canine, 686f-689f
Tarsometatarsaljoints, equine, 7 l6f-7 l9f
Tarsus, 142t. Seealso Metatarsophalangeal
joints; Metatarsus.
canine/feline
anatomy of, 686f-689f
hypertrophic osteopathy of, 202, 202f
osteochondrosisaffecting, 146-147,148f
polyarthritis of, 201-202, 20lf
sesamoidbones of, 1881,189
equine,222-226
anatomy of,716f-719f
rracrureor, zlJ-Lzo
infection of, 225f, 226, 226f
osteoartnrlllsott zz5, zz+r
osteochondrosisof, 222-223, 223f, 224f
radiographic technique for examination of,
222
synovial cavities of, 222
tarsal bone collapsein, 224,225f
T eet h , 7 2 , 7 2 t
canine/feline
abscessaffecting, 80-81, 82f
alveolarcrest ol, /2, /zI, 6zf
anatomy of, 72, 72f, 72t, 689f-694f
deciduous vs. permanent, 72t
feline in,72,72t
hyperparathyroidism affecting, 73, 75f
lamlna oura o\ / z, / zr
namber of,72,72t
periodontal membrane of,72, 72f
p u l p c a v i t y s i z ei n , 7 2 ,7 2 f
equine, 87-89, 88f, 725f, 726f
abscessof, 96f, 97, 97f
Temporomandib :uJarj oint, 72
canine, 66f, 67f,73,74f, 692f
dysplasiaof,73,74f
equine,67f
feline, 82f
jaw locking related to,73, 74f
Tendons
canine/feline, 196-199
joint trauma affecting, 196-199
equine
metacarpal/metatarsal,254158, 255f-258f
metacarpophalangeal/metatarsophalangeal,
2s9,274f,275f
phalangeal,27l, 274f, 275f
Testes,610-612, 614
canine/feline,610-612, 614
Testes(Continued)
anatomy of, 487
feminization related to, 487
imaging procedurefor, 610, 610f
intra-abdominal,610-61l, 6l 1f
intrascrotal,6Il-612, 62If
m a ssr n, 6Iz, ol zr
normal, 610, 610f
Tetralogy of Fallot, canine/feline, 413-414, 4I5f
Thickness, radiopacity related to, 43f, 44,44f
Thoracic wa]^\,349-359
canine/feline, 349-3 59
extrapleural (mass effect) sign in, 351-357,
3 5sf,356f
nipple appearancein, 46, 48f,350,352f
normal appearance of, 349-350, 350f-353f
ribs in, 350f-352f, 351-357
agenesis/hypoplasiaaffecting, 351, 35zf
costochondral mineralization and, 350,
J5 -tI
fractures affecting, 351, 353f-355f
infection related to, 357, 357f-359f
tumors of, 351-357, 355f-358f
Thorax, 307-322, 349-359. Seealso specifc
organsand structures.
canine/feline, 307-322, 349-359
anatomic regionsof, 310-311, 311f-313f,
376f, 699f
heart in, 309f, 318-322, 3l9f-321f, 376f.
Seealso Heart.
clock face analogy for, 319-320,320f,
403,403f
disordersrelatedto, 320-322, 32lf
vertebral heart score measurement for,
3 18-319
inspiration vs. expiration in, 307-308,
3081,408f
interpretation paradigms for, 310-322
lung in, 310-320, 313t, 3l4f-319f. Seealso
Lung, canine/feline.
a lveol arpatterni n, 313-315, 3I3t, 3 l 5f
bronchial pattern in, 318, 319f
interstitial pattern in, 315-316, 315t,
3r6f,3r7f, 3r8t
nodule in, 308-3 10, 309f, 3 15-3 16, 3 15t,
3r6f
vascularpattern in, 316-318, 318f, 3l8t
mediastinum in, 3ll-312, 3I2f, 313f, 376f
pleural spacein, 3I0, 376f
radiography methods for examination of,
307-310,308f, 3081,309f, 402
equine,451-482
larynx/phar1.nx in, 45 | 463
lung in, 463-475
pieural space in, 475482
Thromboembolism, 424, 472
canine/feline
h e a r tw ormdi seasecausi ng,424,424t,426f
pulmonary artery role in, 424, 424t, 426f
equine pulmonary, 472
"Thumbprint" appearance,intestine with, 653,
655f, 656f
Thymus, canine/feline,J78, 379t, 387f
Thyroid cartilage
canine/feline, 323, 323f, 690f
foreign body vs., 323, 32Jf
Tibia
canine/feline
agenesisof, 149-152, I5lf
anatomy ol 684f-689f
fr a cturesol l 6l f, 165f,170f,171f,l 78f
infection of,1,82f
eqtine, 7 I6f-7 I9f , 7zIf, 722f
Ticks
canine, 182
hepatozoonosisroie of, 182
Tissues
atomic number of, 43-44, 43f, 43t, 44f
bone production within, 139, 140f,174f,
176f
bone vs. soft, 3, 9, 43-44,43f,43t,44f
CT x-ray absorption by,29,29t
gonadal and fetal, safety of, 4
Hounsfield unit attenuation value for, 29,
29r
MRI reiaxationtimes in, 3I-34,31t, 32r
radiopacity of, 43-44, 43f, 43t, 44f
ultrasound interface with,20-22, 2lf, 2It,
22f, 23, nr
x-ray absorption differences in, 2-3, 2f, 4, 9,
9f, 4344, 43f, 43t, 44f
"Tit" sign, pyloric obstruction with, 628
TMI. SeeTemporomandibular joint.
"Toe dancer" stance,equine hoof in, 286,287f
Tooth. SeeTeeth.
Trachea
canine/feline, 324-329, 694f
anatomic factors and, 324-325, 325f, 694f
barium aspirated inIo, 445, 446f
collapseof, 326,327f
displacement (mass effect) in, 324-325,
325f
esophagealgas affecting,326,3Z6f
hypoplasiaof,325-326
inflammation of, 326
pleural effusion effects and, 381,382f
rotation effecton, 326,328f
size (diameter) of, 325-326
"stripe" sign relatedto, 326,326f,343f
tumors of, 325
equine, 459-460, 464f
disorders affecting, 459461, 460f, 46If,
462
guttural pouch displacement of, 455f, 457f,
458f, 460, 460f
pneumomediastinum role of, 460, 460f
rings of, 460, 460f, 46If
surgicalincision of, 460, 46lf
traumatic penetration of, 460-46L, 460f,
46tf
Tracheoesophageal"stripe" sign, 326, 326f, 343f
Transducers.SeeUltrasonography, transducers
used in.
Transformers
step-downvs. step-up,8, 8f
windings of, 7-8,8f
x-ray machine use of, 7-8, 8f
Transverseprocess,59f, 62f
Trauma
canine/feline
aD oomrnalw al l rn, 515-)l d, 516I
carpus in, 206f
diaphragmatic hernia due to, 364f, 365f,
366,366t,367f
gunshot fracturesin, 169, 169f
joint diseasedue to, 195-199,196f, l97f
ligamentsin, 196-199, 197f, I98f
peri l onealspaceand, 5I8, 519 f,527f,528,
528f
skull affected in, 81-83, 83f
tendons in, 196-199
TMI dislocationdue to, 8l-83, 83f
urethra in, 589-591, 590f, 591f
vertebraein, 105, 107f, 108f
equrne
gunshot pharynx in, 455, 456f
stifle in, 219,220f
trachea in, 460-461, 460f, 461f
vertebrae in, 129, l30f
Tricuspid dysplasia,canine/feline, 406f, 414
Tioubleshooting film technique, 17, l7t, l8f
Tumors. Seealso Neoplasia.
 I NDEX 757

Turnors (Continued) Ultrasound (Continued) Ulents (Continued)

canine/feline wave characteristicsof, 20-22, 2Of granuloma of, 605, 607f
b o n e a f f e c t e db y. 1 7 9 - 1 8 6 ,l7 9 f- l8 lf, wavelengthof,20,20f nernlauon oI, bu), bu,/I
18 3 f - 18 s f Unguicular process,canine, 689f mineralization and, 604f, 605, 605f, 608f
infection differentiatedfrom, 179-186 Ureter, 562-570 pregnancyand, 603-607, 604f, 605f, 607f,
joints affected by, 203f, 204f, 205 canlne/Iellne,Joz-5 / u 608f
pododermatitisvs., 182-184, 184f, l85f abnormal findings for, 562-569, 566f-568f pyometra ol 490i 493, 494f,605, 606f
ribs affectedby. 35l-357, 356f, 358f absenceof, 562 radiographictechniquefor, 603, 603f
Turbinates,equine, 87-89, 88f, 96f anatomy of, 486f, 487,487f ultrasonography of, 603-604, 604f406f
Tympanic b,llla, 72, 72f calculi in, 563f, 566, 568f Uterus masculinus,602
canlne, bf[, oor, /l,r ectopic,566, 566f, 567f, 574f
anatoml- of, 689f' 692f normal, ))6r, 55)r, >oz
otitis affecting,78-80, 80f-82f obstruction of, 563f, 564f
equine, 67f opacity patterns ol 563f, 566,566f-568f "Vacuum" sign, 146
rupture affecting, 566, 568f canine/feline
gas causing,146, 1.17f
U ureterocele affecting, 566, 567f, 58lf
Ureterocele,canine/feline,566, 567f, 581f osteochondrosisrrith, I46, 147f
Ulcers, 628-629 Urethra, 588-592 Vaginographl', 6 12-6 I 3
canine/feline canine/feline,588-592 cani ne/fel i ne,
589f,bl l -{l J, bl l f
intestinal pseudoulcersas,642, 644f a natomyol 487, 588, 588f Valgusdeformiq' (knock-knee),equine,
l4t -)t) 111f
malignant, 628, 629f cal cul iol 588, 589, 590f
stomach affected b1', 628-629,629f \rah-ulardisease,413--115
contrast studiesof, 588-589, 589f-591f
Ulna femal evs. mal e,588 i 89,588f-591f canine/feline
canine/feline filling defectsof, 589, 590f aorti c stenosi si n, .1101413
anatomy of,678f-582f neoplasiaaffecting,5891 590f mitral insufficienry in, 404f, 414415, 427f
fracturesof, 162f-1661 172f, 176f-)'78f, prostategland affecting,593, 594f, 597f, pulmonary stenosisin, 406f, 409, 413
196f tricuspid dysplasiaLn,406f, 414
598,598f
Varus deformity (bow-leg), eqdne, 241-242,
fragmentedcoronoid processof, 149, radiographicevaluationof, 588-591, 588f-
243f
I )UI-1) 1t 59),f
Velocity
h l p e r t r o p h i co s te o d ystr o p hoyf. 1 5 2 - 1 5 3 . traumatic injury to, 589-591, 590f, 59lf
electromagnetic radiation with, 1
I )JI ultrasonographyof, 589, 590f
ultrasound waves with, 20, 2lt
infarction ol 180f Urinary bladder,57I-587
Vena cava, canine/feline, 308, 308f, 376f
infection of, 183f, 184f canine/feline
cattdal,406-407
panosteitis affecting, 152, I52f anatomy of, 486f, 487, 487f, 571-572,
Ventricle(s),403,4I4
retainedcartilagecore in,157, I57f s7rf, 572f
canine/feline
tumor of, r79f, rSof calculi of, 573-575,5751,580f, 584-585,
enlargement of, 403-406, 406f-408f
equine, 702f-7 O6f, 720f, 7zlf 58sf
septal defect of, 4I3, 414f
anatomy of, 702f-706f, 720f,721f "cobblestone" appearance of, 576, 579f
Vertebrae. Seealso lntervertebral disc disease;
Ultrasonography,20-27. Seealso Ultrasound. colon displacementby, 661f, 662,662f
Spine.
a c o u s t i ci m p e d a n cein . 2 0 - 2 1 . 2 1 f, 2 lt contrast studies of, 575-577, 57 6f-584f,
canine/feline, 57-63, 98-109
a r t ) l a c t sr n , - J - : " :- 1 1 - :/l 576L 578t,5801,587f
alignment problems of, 101, 10lf
acousticenhancementform of, 26, 27f disordersaffecting,573t, 575t, 5781,5801
anatomyof, 58f, 59f, 62f,7 0f,71,98-99,
acousticshadorr'tbrm ot-,)+-26, 26f d ispl acementof, 572, 573t,574f,593,594f 11If,683f,694f-698f
edge-shadorringtbrm ot, l-1, l6f d i stenti onof, 493,495f,496f,572,572f
anomal i esof, 99-101,991 l 00f
m i r r o r - i m a c et or m o l l- 1 .l{ i d fvertrcutaot, 5/ /, >6zl "anticlinal," 100
pseudo-sludgetbrm of. li. l-ii fill i ng defectof,576-577,578t.580( 580t. "bl ock,"99, 991 100,101f
reverberationtbrm oi. 13. l-lf s81f, 5821 584f "butterfly," 100
s i d ea r d s r a t i n s lo h e lb r m s o t- ,lJ, l5 f g asi n, 573, 574f,575f,580f,582, 583f caudal,58f, 683f
slice thicknesstbrm ot, 13-14, 25f "honeycomb" appearanceof, 583f
degenerativeabnormalitiesol 10I-103,
basic phvsicalprinciples ot, 20-22, 20f, 2ll Intecl l onoT,J/5, >/+r, ),/)l r 5d), )d)l t02f-r04f
If inflammation of, 573, 574f,5751 585f fracture affecting,105, l07i 108f
brightnessls. attenuationin, 23, 23t neoplasiaaffecting,577, 58Ct,58lf, 585- "hemivertebrae"and, 99, 99f, i00
displar-in. Jl-l,i s86, 585f infection oi 104, 105f
B - m o d e .l l - 1 , 1 n ormal , )/ t-t/2, >/ tt, t/zl inflammation of, 104, 105f
gral'scale.ii-l-l "pelvic," 572, 573t, 574f lumbarization/sacralization in, 100
ilI-mode. ll-l-l peritoneal fluid affecting, 572, 573f metabolic/endocrine effects in, 103-104,
e c h o e si n , l 0 - l - r . l]f. lli 2 3 t prostate gland and, 593, 594f 104f
image formation in. ll-li radiographic signs related to, 572-582, neoplasiaaffecting,i04-105, 106f, l07f
scanner(porrer controls tbr, 21-22 s73f-57 5f, 575t, s77f, 578t, 579f-584f number abnormalities in, 99-101
s o u n d w a v e su s e din . lCt- - ll, 2 0 f,2 1 f,zlt st ze ol,5/ l-J/2, )/5t ri b formati on and,99-100,99f, 101
spatialpulse length SPLr tn, 20, 22, 22f ultrasonography of, 582-586, 584f, 585f spina bifida affecting, 99-100, l00f
t i s s u ef a c t o r si n , l 0- ll. l1 t, llt, ) .2 f,2 3 ,2 3 t artifactsin, 25f,26f subluxationof,99, 100, l00i 101, 101f,
t r a n s d u c e ru s s e d i n, ll- ll, lli wall thickening of, 576, 579f,5801,585, 102f,r05, 108f
e l e c t r o n r c2, I - : : , ::l s85f "transitional," 99-I00, 99f
mechanical,2l Urography, 556-562 trauma to, 105, l07i 108f
p i e z o e l e c t r iccr vsta .ls o l. ll in canine/feline patients, 556-562, 557t, wobbler syndrome of, i01
r e s o l u t i o no f , l l -ll. llf 558f-560f, 562t equine, 57, 58f, 59f, 63,63f, 127-133
sector-shaped, 2 1-22 quantitative measurements rn, 557, 557t ataxia role of, \29-133,129f, l3lf-133f
Ultrasound, l0-22 technique for, 556-557, 556t cervical,724f
angle of incidenceot-,l0-ll, 2lf Uterus, 603-607, 614 congenital anomalies of, 128-129, l29f
b a s i cp h v s i c so t . l 0- ll. l0 i canine/feline, 603-607, 614 disordersaffecting,63,63f, L27-133, I28f-
beam rt'idth ol 2l anatomy of, 487, 603f, 604f l 33f
*od1aen.1e<
^t
) lLtl )llt enlargernent of, 493, 494f,604-605, 606f, fracture affecting, 129, I30l
reflectionand transmittanceof, 20-2I, 2If 607f infections of, 129, 130f, I32
tissue interface wirh, 20-22, 21f, 2lt, 22f fetus in, 603-607, 604f, 605f, 608f myelography of, 128, 128f, 130, I32f, 133,
velociry of, 20, 21t gas in, 605, 608f l33f
7A 754 INDEX
Vertebrae (Continued)
,Syn
radiography of, 63, 63f, 127-133, 128f-
r33f
sacral
anatomy of,723f
sacroiliac subluxation in, 129
trauma to, 129, l30f
wobbler syndrome and, 129-133
Views, 47, 49f
radiographic naming system for, 47, 49f
Visual perception (human), 3541, 47
Syr
acute vision field size in, 40
Syst
errors/distortions in, 35-41, 35f4lf, 47, 49f
radiograph interpretation and, 3541, 35f-
4 r f , 4 7 ,4 9 f
saccadicmovement role in, 39-41, 41f
K
Tail
shifting stability phenomena in, 38' 40f
theories of, 3541, 35f4lf
vision searchpatterns in,3941' 4Lf
Vitamin A, bony proliferation due to, 103
Vitamin D, bone metabolism affectedby, 137
Voltage, piezoelectric crystals rcceiwng, 22
Volvulus, 623-626, 651-652
canine/feline
IAI'
( small intestine in, 651-652
stomach in, 623-626, 625f-627f
Vomer bone, canine/feline, 71
Tar
Tar
Tar
'Wagon wheel" appearance,620,644
ileocolic junction with, 644
"Wagon wheel" appearance(Continued)
stonlach with, 620, 62If
Water
atomic number of,4344, 43f, 43t
CT x-ray absorptionby,29,29t
magnetization relaxation time in, 311,
32t
radiopacity dre to,43-44, 43f, 43t
sound wave impedance in, 21t
Wavelength
elecromagnetic radiation with, I, lt,2f
ultrasound with, 20, 20f
White matter
CT x-ray absorption by,29,29f
magnetization relaxation time in, 31t
"Windswept" appearance, equine carpus role
in,243f
Wobbler syndrome
canine, 101, 123
equine, 129-133
Xeroradiography,equineanatomyn, 702f-726f
X-rays,1-10. SeealsoRadiation;Radiographs.
absotptionof,2-3,2f, 4,9,9f., 4344, 43f,
43t, 44f
basicpropertiesof, l, lt,2f,2t
biologicalmatterinteractionsof, 1-5, 2f, 8-
10,9f
5, 6f, 9f
"characteristicj'
directional terms relatedto, 47, 49f
&sQ8d3
X-rays (Continued)
discovery of, I
distance from target and, 10-11, llf
filrn exposure to, 10-17, 10f-16f, 17t
filtering of, 10, lOf
grid absorption of, 14-15, l4f,75f
per unit area, 10-11, 1lf
photon energy specffum of,6,6f
production of, 5-10, 5f-10f
collision model for, 5, 6l
equipment for, 5-10, 5f,7f, 8f, 10f
generators used in, 7-8
radiative model for, 5, 6f
radiographic processusing, 10f*16f, 10-17,
17t
ripple factor related to, 8, 8f
scattered,9-10, 9f
photon energy spectrum of, 6, 6f
X-ray tubes, 5-10, 5f, 7f,8f, Ilf
collimator for, 10, 10f
filters with, 10, tOf
focal spot size of,12, l2f, l3f
Yawning,jaw locking dueto,73,74f
Zinc toxicity, pennies causing, 645
Zygomatic arch, canine, 65f, 66f, 69 Lf, 692f
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