ANSWER

Left T1 transverse process

Here we have a frontal chest X-Ray. The key to this question is being able to recognise which is the first thoracic vertebra. The best way to do this is to look for the shape of the transverse processes – cervical transverse processes tend to point downwards whilst thoracic transverse processes tend to point upwards.

In this question the arrow is pointing at the first transverse process which is pointing upwards making it the T1 transverse process. Remember the processes projecting laterally are the transverse processes and the ones in the centre that you can see end on are the spinous processes.

KEY POINT

Transverse processes of the thoracic vertebrae point upwards, transverse processes of the cervical vertebrae point downwards

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INFERIOR VENA CAVA

This is an image of an abdominal ultrasound. Here we can see the liver with three vessels heading out from the centre of the image. This is known as a ‘crow’s foot’ view (although this is what I was told but looking it up it seems no one else seems to call it that, I think it’s a good name for it anyway). The three vessels are the hepatic veins heading into the IVC which we can see centrally running through the liver.

Along with the falciform ligament and portal vein, the hepatic veins can help us divide the liver into different segments (Couinaud classification). In radiology we use this fairly frequently to describe the location of liver lesions so it is pretty essential knowledge when you are starting out.

It may look a bit confusing but I’ve always remembered it in this way starting from the left:

• 2 goes above 3. Because usually you go for a number 2 upstairs (sorry, what am I even talking about)
• Next are the 4s with 4a above 4b
• Then comes a square, going in a spiral starting bottom left, 5 to 6 to 7 to 8
• 1 is the caudate lobe

KEY POINT

When you see the hepatic veins heading into the IVC on ultrasound this tells you are at the superior aspect of the liver.

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COELIAC AXIS

This is an image of an abdominal MRI. Here we can see the aorta and a ‘seagull shaped’ vessel arising from this: this is the characteristic shape of the coeliac axis. We can see one of the branches here, the splenic artery with the beginnings of one of the other branches – the common hepatic artery. The third branch is not seen on this slice (the left gastric artery).

The coeliac axis is the first of three main visceral branches of the abdominal aorta coming off at T12. Next is the superior mesenteric artery at L1 (always look for a fat halo surrounding this on CT, MRI or US) and then the much smaller inferior mesenteric artery coming off at L3 before the aorta bifurcates at L4.

KEY POINT

Remember the branches of the coeliac axis with the mnemonic ‘GoSH it’s a seagull’

left Gastric artery

Splenic artery

common Hepatic artery

ANSWER

LEFT MAIN RENAL ARTERY

KEY POINT

Remember the IVC runs to the right of the aorta: I remember the phrase ‘right VC’ although admittedly that makes no sense at all.

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MAIN PORTAL VEIN

This is an ultrasound of the liver combined with colour Doppler. Doppler imaging allows us to assess both the velocity and direction of blood flow. The machine can assign different colours depending on the direction of flow, classically:

 

Colour	Direction
Red	Towards the transducer
Blue	Away from the transducer

The question however asks about the sartorius muscle which sits at the front. Think of it as the ‘sargeant’, leading the other muscles. This can be remembered with the mnemonic ‘BART’.

We are at the porta hepatis. We can see the gallbladder. In normal circumstances this should contain anechoic (black) fluid on ultrasound without any sludge, calculi or polyps. The blue vessel we can see is the hepatic IVC whilst we can also see the common hepatic artery. The arrowed structure in this case is the main portal vein.

KEY POINT

In normal circumstances the main portal vein should show antegrade flow TOWARDS the liver and so when scanning in the intercostal position, should appear red on Doppler imaging.

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SARTORIUS

Here we have an MRI image of the pelvis at the level of the neck of femur. Anterior to the femur we can see the iliopsoas muscle which is on its way to insert onto the lesser trochanter of the femur.

There are two muscles lateral to this which are the rectus femoris and the tensor fascia lata.

The question however asks about the sartorius muscle which sits at the front. Think of it as the ‘sargeant’, leading the other muscles.

KEY POINT

The sartorius muscle originates at the anterior superior iliac spine and spirals round to insert at the medial surface of the proximal femur.

The tensor fascia lata also attaches to the anterior superior iliac spine.

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RIGHT T5 PEDICLE

Again we have an adult PA chest X-Ray. Don’t forget to review the spine if you can see it on a chest X-Ray. This question points at a small circle we can see: this is a pedicle.

Looking closely we can see two small circles related to each vertebra – this correlates with the two pedicles that form a bridge between the vertebrae and the rest of the posterior elements. Have a look at this labelled image of a thoracic vertebra in cross-section.

Which vertebra are we looking at? We can see that the T1 vertebra is the one where the first ribs come off and the transverse processes point upwards rather than down as seen with cervical vertebrae.

Count down and we find we are at the T4 level. So this is the right T5 pedicle.

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RENAL SINUS FAT

Here we have an ultrasound image of the liver and right kidney.

On ultrasound we use the term hyperechoic to mean bright and hypoechoic to mean dark. Isoechoic means the ‘same echogenicity’ as another structure whilst anechoic means completely black (usually representing simple fluid).

The hyperechoic area we can see at the centre of the kidney relates to renal sinus fat. The adjacent liver should be isoechoic (same brightness) or very slightly hyperechoic (brighter) when compared with the kidney. In this case the liver is isoechoic as it should be. If the liver becomes very hyperechoic (bright) compared with the kidney then we have to consider fatty infiltration of the liver. 

This is the opposite to CT where in hepatic steatosis the liver becomes darker. Best called on non contrast CT, we can call this when the liver is at least 10HU lower in attenuation than the spleen or lower than 40HU in total.

ANSWER

RIGHT FEMORAL VEIN

Here we can see the pelvis at the level of the ischium. We can see the femoral vessels – we can see the femoral vein sitting medial to the artery.

As a junior radiology registrar I was taught to call this the SFV or superficial femoral vein in my ultrasound reports. However we should try and avoid calling it this as it can make it seem like a superficial vein whilst it is considered part of the deep venous system.

The femoral vein forms at the adductor hiatus as a continuation of the popliteal vein. The deep femoral and great saphenous vein drain into it at which point it becomes the common femoral vein. We can see the great saphenous vein is about to join up with the femoral vein to make the common femoral vein.

KEY POINT

The common femoral, femoral and popliteal veins are important structures when screening for a deep vein thrombosis on ultrasound. Avoid using the term ‘superficial femoral vein’ as this can mean the femoral vein is mistaken for a superficial vein.

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NAVICULAR

Here we have an oblique view from a foot X-Ray. Standard projections you may see include a dorsoplantar or ‘DP’ which aims to show the majority of the bones en face as well as a lateral. This question asks about a bone on the medial side of the foot which we can see articulating proximally with the talus and also with the three cuneiform bones and cuboid which we can see laterally proximal to the 5th metatarsal.

This is the navicular bone which translates as ‘small ship’. Although in humans this isn’t really a ship shaped bone, it is in horses.

Also well done if you spotted that one of the options ‘lateral cuboido’ is a completely made up term. I thought you may be a bit tired getting to the end of the quiz, I know I am.

KEY POINT

Fractures of the navicular are uncommon but can arise as stress fractures in athletes or in high intensity trauma.