Clinical Emergency Radiology 2nd Edition by

Christian Fox ISBN 1107065798 978-1107065796

download

https://ebookball.com/product/clinical-emergency-radiology-2nd-
edition-by-christian-fox-isbn-1107065798-978-1107065796-6118/

Instantly Access and Download Textbook at https://ebookball.com

 Get Your Digital Files Instantly: PDF, ePub, MOBI and More
Quick Digital Downloads: PDF, ePub, MOBI and Other Formats

Clinical Emergency Radiology 2nd Edition by Christian Fox

9781316588635 1316588637

https://ebookball.com/product/clinical-emergency-radiology-2nd-
edition-by-christian-fox-9781316588635-1316588637-1634/

Pediatric emergency medicine An Issue of Emergency Medicine Clinics of

North America 1st edition by Sean Fox, Dale Woolridge ISBN 0323583504
978-0323583503

https://ebookball.com/product/pediatric-emergency-medicine-an-
issue-of-emergency-medicine-clinics-of-north-america-1st-edition-
by-sean-fox-dale-woolridge-isbn-0323583504-978-0323583503-4550/

Emergency Radiology The Requisites 2nd Edition by Brian Lucey,Jorge

Soto 9780323340861 0323340865

https://ebookball.com/product/emergency-radiology-the-
requisites-2nd-edition-by-brian-lucey-jorge-
soto-9780323340861-0323340865-6022/

Pediatric Emergency Medicine 2nd Edition By Alisa McQueen, Margaret

Paik ISBN 1482230291 978-1482230291

https://ebookball.com/product/pediatric-emergency-medicine-2nd-
edition-by-alisa-mcqueen-margaret-paik-
isbn-1482230291-978-1482230291-4494/
Examination Review for Ultrasound Sonographic Principles and
Instrumentation 2nd edition by Steven Penny, Traci Fox ISBN
149637732X 978-1496377326

https://ebookball.com/product/examination-review-for-ultrasound-
sonographic-principles-and-instrumentation-2nd-edition-by-steven-
penny-traci-fox-isbn-149637732x-978-1496377326-6268/

Errors in Emergency and Trauma Radiology 1st edition by Michael

Patlas,Douglas Katz,Mariano Scaglione 3030055485 9783030055486

https://ebookball.com/product/errors-in-emergency-and-trauma-
radiology-1st-edition-by-michael-patlas-douglas-katz-mariano-
scaglione-3030055485-9783030055486-6054/

Roberts and Hedges Clinical Procedures in Emergency Medicine Expert

Consult 6th Edition by James Roberts 145570606X 978-1455706068

https://ebookball.com/product/roberts-and-hedges-clinical-
procedures-in-emergency-medicine-expert-consult-6th-edition-by-
james-roberts-145570606x-978-1455706068-2860/

Dairy Chemistry and Biochemistry 2nd edition by Fox, Uniacke Lowe,

McSweeney, JO'Mahony ISBN 3319374362 9783319374369

https://ebookball.com/product/dairy-chemistry-and-
biochemistry-2nd-edition-by-fox-uniacke-lowe-mcsweeney-jo-mahony-
isbn-3319374362-9783319374369-8546/

Pocket Atlas of Emergency Ultrasound 2nd edition by Robert Reardon,

John Ma, Andrea Rowland Fisher ISBN 0071848983 978-0071848985

https://ebookball.com/product/pocket-atlas-of-emergency-
ultrasound-2nd-edition-by-robert-reardon-john-ma-andrea-rowland-
fisher-isbn-0071848983-978-0071848985-6178/
Cambridge University Press
978-1-107-06579-6 — Clinical Emergency Radiology
Edited by J. Christian Fox
Frontmatter
More Information

Clinical Emergency Radiology

Second Edition
This book is a highly visual guide to the radiographic and advanced imaging modalities –
such as computed tomography and ultrasonography – that are frequently used by physicians
during the treatment of emergency patients. Covering practices ranging from ultrasound at
the point of care to the interpretation of CT scan results, this book contains more than 2,200
images, each with detailed captions and line art that highlight key findings. Within each
section, particular attention is devoted to practical tricks of the trade and tips for avoiding
common pitfalls. This book is a useful source for experienced clinicians, residents, mid-level
providers, and medical students who want to maximize the diagnostic accuracy of each
modality without losing valuable time.

J. Christian Fox received his undergraduate degree at University of California, Irvine, and his MD at
Tufts Medical School. Since joining the UC Irvine faculty in 2001 as Chief of the Division of Emergency
Ultrasound, he has directed the Ultrasound Fellowship. In 2010 he created a fully integrated four-year
ultrasound curriculum at the School of Medicine. He is the editor of Clinical Emergency Radiology as
well as Atlas of Emergency Ultrasound, and has authored over eighty articles on ultrasound.

© in this web service Cambridge University Press www.cambridge.org

Cambridge University Press
978-1-107-06579-6 — Clinical Emergency Radiology
Edited by J. Christian Fox
Frontmatter
More Information

Clinical Emergency Radiology

Second Edition

Edited by
J. Christian Fox
University of California, Irvine

© in this web service Cambridge University Press www.cambridge.org

Cambridge University Press
978-1-107-06579-6 — Clinical Emergency Radiology
Edited by J. Christian Fox
Frontmatter
More Information

University Printing House, Cambridge CB2 8BS, United Kingdom

One Liberty Plaza, 20th Floor, New York, NY 10006, USA
477 Williamstown Road, Port Melbourne, VIC 3207, Australia
4843/24, 2nd Floor, Ansari Road, Daryaganj, Delhi – 110002, India
79 Anson Road, #06–04/06, Singapore 079906

Cambridge University Press is part of the University of Cambridge.

It furthers the University’s mission by disseminating knowledge in the pursuit of
education, learning, and research at the highest international levels of excellence.

www.cambridge.org
Information on this title: www.cambridge.org/9781107065796
© J. Christian Fox 2017
This publication is in copyright. Subject to statutory exception
and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without the written
permission of Cambridge University Press.
First published 2008
Second edition 2017
Printed in the United States of America by Sheridan Books, Inc.
A catalog record for this publication is available from the British Library.
ISBN 978-1-107-06579-6 Hardback
Cambridge University Press has no responsibility for the persistence or accuracy of
URLs for external or third-party internet websites referred to in this publication,
and does not guarantee that any content on such websites is, or will remain,
accurate or appropriate.
..............................................................................................................................

Every effort has been made in preparing this book to provide accurate and
up-to-date information that is in accord with accepted standards and
practice at the time of publication. Although case histories are drawn from
actual cases, every effort has been made to disguise the identities of the
individuals involved. Nevertheless, the authors, editors, and publishers can
make no warranties that the information contained herein is totally free
from error, not least because clinical standards are constantly changing
through research and regulation. The authors, editors, and publishers
therefore disclaim all liability for direct or consequential damages resulting
from the use of material contained in this book. Readers are strongly
advised to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.

© in this web service Cambridge University Press www.cambridge.org

Cambridge University Press
978-1-107-06579-6 — Clinical Emergency Radiology
Edited by J. Christian Fox
Frontmatter
More Information

Contents
List of Contributors vii

Part I–Plain Radiography 16 Deep Venous Thrombosis 239

Eitan Dickman, David Blehar, and Romolo Gaspari
1 Plain Radiography of the Upper Extremity in
Adults 1 17 Cardiac Ultrasound 247
Kenny Banh and Gregory W. Hendey Chris Moore and James Hwang

2 Lower Extremity Plain Radiography 11 18 Emergency Ultrasonography of the Kidneys and

Anthony J. Medak, Tudor H. Hughes, and Stephen Urinary Tract 261
R. Hayden Anthony J. Dean and Ross Kessler

3 Chest Radiograph 41 19 Ultrasonography of the Abdominal Aorta 276

Peter DeBlieux and Lisa Mills Deepak Chandwani

4 Plain Film Evaluation of the Abdomen 55 20 Ultrasound-Guided Procedures 284

Anthony J. Dean and Ross Kessler Daniel D. Price and Sharon R. Wilson

5 Plain Radiography of the C-spine 79 21 Abdominal–Pelvic Ultrasound 313

Eric Fox Silman Mike Lambert

6 Thoracic and Lumbar Spine 96 22 Ocular Ultrasound 324

Olusola Balogun, Natalie Kmetuk, and Christine Viet Tran and Zareth Irwin
Kulstad 23 Testicular Ultrasound 331
7 Plain Radiography of the Pediatric Extremity 107 Paul R. Sierzenski and Gillian Baty
Kenneth T. Kwon and Lauren M. Pellman 24 Abdominal Ultrasound 338
8 Plain Radiographs of the Pediatric Chest 120 Shane Arishenkoff
Loren G. Yamamoto 25 Emergency Musculoskeletal Ultrasound 346
9 Plain Film Radiographs of the Pediatric Tala Elia and JoAnne McDonough
Abdomen 144 26 Soft Tissue Ultrasound 359
Loren G. Yamamoto Seric S. Cusick and Katrina Dean
10 Plain Radiography in Child Abuse 174 27 Ultrasound in Resuscitation 368
Kenneth T. Kwon and Lauren M. Pellman Anthony J. Weekes and Resa E. Lewiss
11 Plain Radiography in the Elderly 178
Ross Kessler and Anthony J. Dean
Part III–Computed Tomography
28 CT in the ED: Special Considerations 401
Part II–Ultrasound Tarina Kang and Melissa Joseph
12 Introduction to Bedside Ultrasound 195 29 CT of the Spine 407
Michael Peterson and Zahir Basrai Michael E. R. Habicht and Samantha Costantini
13 Physics of Ultrasound 201 30 CT Imaging of the Head 422
Seric S. Cusick and Theodore J. Nielsen Marlowe Majoewsky and Stuart Swadron
14 Biliary Ultrasound 211 31 CT Imaging of the Face 439
William Scruggs and Laleh Gharahbaghian Monica Kathleen Wattana and Tareg Bey
15 Trauma Ultrasound 227 32 CT of the Chest 456
Bret Nelson Jonathan Patane and Megan Boysen-Osborn
v

© in this web service Cambridge University Press www.cambridge.org

Cambridge University Press
978-1-107-06579-6 — Clinical Emergency Radiology
Edited by J. Christian Fox
Frontmatter
More Information

Contents

33 CT of the Abdomen and Pelvis 469 39 MRI of the Brain 519

Nichole S. Meissner and Matthew O. Dolich Asmita Patel, Colleen Crowe, and Brian Sayger
34 CT Angiography of the Chest 479 40 MRI of the Spine 538
Swaminatha V. Gurudevan and Reza Arsanjani Aaron J. Harries, Andrew V. Bokarius, Armando
S. Garza, and J. Christian Fox
35 CT Angiography of the Abdominal Vasculature 484
Kathleen Latouf, Steve Nanini, and Martha Villalba 41 MRI of the Heart and Chest 559
Jonathan Patane, Bryan Sloane, and Mark Langdorf
36 CT Angiography of the Head and Neck 495
Saud Siddiqui and Monica Wattana 42 MRI of the Abdomen 568
Lance Beier, Nilasha Ghosh, Andrew Berg, and
37 CT Angiography of the Extremities 505
Andrew Wong
Nilasha Ghosh, Chanel Fischetti, Andrew Berg,
and Bharath Chakravarthy 43 MRI of the Extremities 583
Kathryn J. Stevens and Shaun V. Mohan

Part IV–Magnetic Resonance Imaging

38 The Physics of MRI 515
Joseph L. Dinglasan, Jr., and J. Christian Fox Index 630

vi

© in this web service Cambridge University Press www.cambridge.org

Cambridge University Press
978-1-107-06579-6 — Clinical Emergency Radiology
Edited by J. Christian Fox
Frontmatter
More Information

Contributors

Kenny Banh Laleh Gharahbaghian

University of California, San Francisco – Fresno Stanford University

Gregory Hendey Bret Nelson

University of California Los Angeles Mount Sinai University

Peter DeBlieux Eitan Dickman

Louisiana State University Maimonides Medical Center
Lisa Mills David Blehar
University of California, Davis University of Massachussets

Anthony J. Dean Romolo Gaspari

University of Pennsylvania University of Massachussets

Ross Kessler Chris Moore

University of Michigan Yale University
Eric Fox Silman James Hwang
University of California, San Francisco Scripps Memorial Hospital, La Jolla, California

Olusola Balogun Deepak Chandwani

University of Illinois, Chicago Christ Hospital University of California, Riverside

Natalie Kmetuk Daniel D. Price

University of Illinois, Chicago Christ Hospital Alameda County Medical Center, Highland Hospital
Christine Kulstad Sharon R. Wilson
University of Illinois, Chicago Christ Hospital University of California, Davis

Kenneth T. Kwon Michael Lambert

Mission Hospital, Mission Viejo, California University of Illinois, Chicago Christ Hospital

Lauren Pellman Viet Tran

University of Nevada, Las Vegas Garden Grove Medical Center, California
Loren G. Yamamoto Zareth Irwin
University of Hawaii Legacy Emanuel Medical Center, Portland, Oregon

Michael Peterson Paul R. Sierzenski

University of California, Los Angeles Christiana Care Health System, Delaware

Seric S. Cusick Gillian Baty

Hoag Hospital University of New Mexico
Theodore Nielsen Shane Arishenkoff
FujiFilm SonoSite, Inc University of British Columbia

William Scruggs Tala Elia

University of Hawaii Tufts University vii

© in this web service Cambridge University Press www.cambridge.org

Cambridge University Press
978-1-107-06579-6 — Clinical Emergency Radiology
Edited by J. Christian Fox
Frontmatter
More Information

List of Contributors

JoAnne McDonough Martha Villalba

Ellis Medicine, Schenectady, New York Jesse Brown Veterans Affairs Medical Center, Chicago,
Illinois
Katrina Dean
University of California, Irvine Saud Siddiqui
George Washington Univeristy Hospital
Anthony J. Weeks
Carolinas Medical Center, Charlotte, North Carolina Nilasha Ghosh
Northwestern University
Resa E. Lewiss
University of Colorado Chanel Fischetti
Duke University
Tarina Kang
University of Southern California Andrew Berg
Northwestern University
Melissa Joseph
University of Southern California Bharath Chakravarthy
University of California, Irvine
Michael E. R. Habicht
Barton Memorial Hospital, South Lake Tahoe, California Joseph Dinglasan
St. Judes Hospital, Fullerton California
Samantha Costantini
University of California, Irvine Asmita Patel
University of Illinois, Chicago Christ Hospital
Marlowe Majoewsky
University of Southern California Colleen Crowe
Medical College of Wisconsin
Stuart Swadron
University of Southern California Brian Sayger
University of Illinois, Chicago Christ Hospital
Monica Wattana
University of Texas, Houston Aaron Harries
Alameda County Medical Center, Highland
Tareg Bey Hospital
Saudi Arabia
Andrew V. Bokarius
Jonathan Patane University of Chicago
University of California, Irvine
Armando S. Garza
Megan Osborn Orange Coast Memorial Medical Center, Fountain Valley,
University of California, Irvine California
Nichole Meissner Bryan Sloane
Kaweah Delta Medical Center, Visalia, California University of California, Los Angeles
Matthew Dolich Mark Langdorf
University of California, Irvine University of California, Irvine
Swaminatha V. Gurudevan Lancelot Beier
Healthcare Partners Medical Group, Glendale, California Virginia Commonwealth University
Reza Arsanjani Andrew Wong
Cedars-Sinai Medical Center, Los Angeles, California University of California, Irvine
Kathleen Latouf Kathryn J. Stevens
Canonsburg Hospital, Pennsylvania Stanford University
Steve Nanini Shaun V. Mohan
University of Illinois, Chicago Christ Hospital Stanford University
viii

© in this web service Cambridge University Press www.cambridge.org

 Part I Plain Radiography
Chapter
Plain Radiography of the Upper Extremity

1 in Adults
Kenny Banh and Gregory W. Hendey

Plain radiography remains the imaging study of choice for

most applications in the upper extremity. Far and away the
most common indication for plain radiography in the upper B
extremity is acute trauma. The shoulder, humerus, elbow, A
forearm, wrist, and hand are common radiographic series
that are useful in diagnosing an acute fracture. Other imaging C
modalities such as CT, ultrasound, and MRI are not generally E
indicated in acute trauma but have an important role in
F
diagnosing soft tissue pathology. G
Another common indication for plain radiography of the D
upper extremity is the search for a foreign body in a wound.
Plain films are an excellent modality for detecting common,
dense foreign bodies in wounds, such as glass and rock, but
they are much less sensitive in detecting plastic or organic
materials (1). Other imaging modalities such as CT, ultra- H
sound, and MRI are superior for detecting organic and plastic
foreign bodies (2). The principles of using plain films for
foreign body detection are similar regardless of the location
in the body and are not discussed in further detail here.
S.JOHNSON, M.D.

In this chapter, discussion of the upper extremity is divided

into three sections: 1) the shoulder, 2) the elbow and forearm,
and 3) the wrist and hand. Within each section, the indications,
diagnostic capabilities, and pitfalls are discussed, followed by
images of important pathological findings.

The shoulder Anterior shoulder. A = acromion, B = clavicle, C = coracoid process, D = neck of

scapula, E = scapular notch, F = greater tuberosity, G = anatomical neck, H =
surgical neck
Indications
The main indication for plain radiography of the shoulder is
acute trauma. There are a number of acute injuries that may time dislocations and those with a blunt traumatic mechan-
be discovered on plain radiography after acute trauma, ism of injury, and postreduction films for those with
including fractures of the clavicle, scapula, and humerus, as a fracture-dislocation. It is also important to order radio-
well as shoulder (glenohumeral) dislocation or acromioclavi- graphs whenever the physician is uncertain of joint posi-
cular (AC) separation. Although many patients may present tion, whether dislocated or reduced. Therefore, it may be
with subacute or chronic, nontraumatic pain, the utility of appropriate to manage a patient with a recurrent disloca-
plain films in that setting is extremely low. For chronic, tion by an atraumatic mechanism without any radiographs
nontraumatic shoulder pain, plain films may reveal changes when the physician is clinically certain of the dislocation
consistent with calcific tendonitis or degenerative arthritis, and the reduction.
but it is not necessary to diagnose such conditions in the
emergency setting. Diagnostic capabilities
Several studies have focused on whether all patients with In most settings, if the plain films do not reveal a pathological
shoulder dislocation require both prereduction and postre- finding, no further imaging is necessary. MRI is an important
duction radiographs (3). Some support an approach of modality in diagnosing ligamentous injury (e.g., rotator cuff
selective radiography, ordering prereduction films for first- 1
tear), but it is rarely indicated in the emergency setting.

09:49:57
01
 Kenny Banh and Gregory W. Hendey

With the possible exception of the scapula, most fractures

of the shoulder girdle are readily apparent on standard plain
Clinical images
Following are examples of common and important findings in
films, without the need for specialized views or advanced
plain radiography of the shoulder:
imaging. The shoulder is no exception to the general rule of
plain films that at least two views are necessary for adequate 1. Clavicle fracture (fx)
evaluation. The two most common views in a shoulder series 2. AC separation
include the anteroposterior (AP) and the lateral, or “Y,” 3. Anterior shoulder dislocation
scapula view. Other views that are sometimes helpful include 4. Posterior dislocation (AP)
the axillary and apical oblique views. The point of the addi- 5. Posterior dislocation (lateral scapula)
tional views is to enhance the visualization of the glenoid and 6. Luxatio erecta
its articulation with the humeral head. These views may be 7. Bankart fx
particularly helpful in diagnosing a posterior shoulder dislo- 8. Hill–Sachs deformity
cation or subtle glenoid fracture. 9. Humeral head fracture
Another radiographic series that is sometimes used is the
AC view with and without weights. Although the purpose of
these views is to help the physician diagnose an AC separa- The elbow and forearm
tion, they are not recommended for the following reasons: 1)
the views might occasionally distinguish a second-degree Indications
separation from a first-degree one, but that difference has Similar to the shoulder, the most common use of elbow and
little clinical relevance because both are treated conserva- forearm plain radiography is with acute trauma. There are
tively, and 2) third-degree AC separations are usually obvious numerous fractures and dislocations that can be easily visua-
clinically and radiographically, without the need for weights lized with plain films. Chronic pain in these areas is often
or additional views. secondary to subacute repetitive injuries of the soft tissue such
as epicondylitis or bursitis. Many of these soft tissue diseases
Imaging pitfalls and limitations such as lateral “tennis elbow” and medial “golfer’s elbow”
epicondylitis are easily diagnosed on clinical exam and gen-
Although most acute shoulder injuries may be adequately
erally require no imaging at all. Plain films may reveal such
evaluated using a standard two-view shoulder series, posterior
soft tissue pathologies as foreign bodies and subcutaneous air.
shoulder dislocation can be surprisingly subtle and is notor-
No well-established clinical decision rules exist for ima-
iously difficult to diagnose. When posterior dislocation is
ging elbows and forearms in acute trauma. Patients with full
suspected based on the history, physical, or standard radio-
range of flexion-extension and supination-pronation of the
graphic views, additional specialized views such as the axillary
and apical oblique can be very helpful. Most radiographic
views of the shoulder may be obtained even when the injured
patient has limited mobility, but the axillary view does require
some degree of abduction and may be difficult.

Figure 1.2. AC separation is commonly referred to as a “separated

shoulder” and can be classified as grade 1 (AC ligament and coracoclavicular
[CC] ligaments intact, radiographically normal), grade 2 (AC ligament
Figure 1.1. Clavicle fractures (A) are often described by location, with the disrupted, CC ligament intact), or grade 3 (both ligaments disrupted,
2 clavicle divided into thirds: proximal, middle, or distal. Note the scapular resulting in a separation of the acromion and clavicle greater than half the
fracture (B) as well. width of the clavicle).

09:49:57
01
 Chapter 1: Plain Radiography of the Upper Extremity in Adults

Figure 1.4. Posterior shoulder dislocation is uncommon and is difficult to

diagnose on a single AP radiograph. Although it is not obvious in this single
view, there are some hints that suggest posterior dislocation. The humeral
head is abnormally rounded due to internal rotation (light bulb sign), and
Figure 1.3. The large majority of shoulder dislocations are anterior, and the the normal overlap between the humeral head and glenoid is absent.
large majority of anterior dislocations are subcoracoid, as demonstrated in
this AP view.

Figure 1.5. Posterior shoulder dislocation is clearly evident on this lateral Figure 1.6. Luxatio erecta is the rarest of shoulder dislocations in which
scapula view, while it was much more subtle on the preceding AP view (see the humeral head is displaced inferiorly while the arm is in an abducted or
Fig. 1.4). This illustrates the importance of obtaining a second view such overhead position.
as the lateral scapula view or axillary view.

09:49:57
01
 Kenny Banh and Gregory W. Hendey

Figure 1.7. Although radiographically subtle, the Bankart fracture is a small

avulsion of the inferior rim of the glenoid. The loss of the glenoid labrum
destabilizes the glenohumeral joint and nearly ensures recurrent
dislocations.

Figure 1.8. The Hill–Sachs deformity is a compression fracture of the

superolateral aspect of the humeral head and is commonly noted in
recurrent shoulder dislocations. It is believed to occur when the humeral
head is resting against the inferior rim of the glenoid while dislocated.

visualized on plain films, but a traumatic joint effusion may

elevate the posterior fat pad enough to be visualized on a 90-
degree lateral radiograph. The anterior fat pad is normally
visualized as a thin stripe on lateral radiographs, but joint
effusions may cause it to bulge out to form a “sail sign” (6).
Traumatic joint effusions are sensitive signs of an intra-
articular elbow fracture (7). In an adult with fat pads and no
obvious fracture, an occult radial head fracture is the usual
culprit.
Figure 1.9. Humeral head fracture often occurs across the surgical neck (A)
but may also occur at the anatomical neck (B). Imaging pitfalls and limitations
The two standard views of the elbow are the AP view and the
elbow and no bony point tenderness rarely have a fracture, lateral view with the elbow flexed 90 degrees. The majority of
and they generally do not require imaging (4). Midshaft fore- fractures can be identified with these two views, but occasion-
arm fractures are usually clinically apparent, and deformity, ally supplementary views may be obtained to identify certain
swelling, and limited range of motion are all indications for parts of the elbow and forearm. The lateral and medial obli-
obtaining radiographs. Some suggest ultrasonography may que views allow easier identification of their respective epi-
reduce the need for elbow radiography (5). condylar fractures. The capitellum view is a cephalad-
oriented lateral view that exposes the radial head and radio-
capitellar articulation. The axial olecranon is shot with
Diagnostic capabilities a supinated and flexed forearm and isolates the olecranon in
In most cases, if no pathology is found in the plain films of the a longitudinal plane.
forearm or elbow, no further imaging is required. Although
obvious fractures are easily visualized on plain film, some
fractures leave more subtle findings. Radiographs of the
Clinical images
elbow in particular may yield important indirect findings. Following are examples of common and important findings in
The elbow joint is surrounded by two fat pads, an anterior plain radiography of the elbow and forearm:
one lying within the coronoid fossa and a slightly larger 10. Posterior fat pad
posterior fat pad located within the olecranon fossa. 11. Radiocapitellar line
4
In normal circumstances, the posterior fat pad cannot be 12. Elbow dislocation, posterior

09:49:57
01
 Chapter 1: Plain Radiography of the Upper Extremity in Adults

Figure 1.10. Subtle soft tissue findings such as this posterior fat pad (A)
and sail sign (B) are markers for fractures that should not be dismissed.

Figure 1.11. A radiocapitellar line is drawn through the radius and should
bisect the capitellum regardless of the position of the elbow.

Figure 1.12. Elbow dislocation is a common joint dislocation,

outnumbered only by shoulder and interphalangeal dislocations. Most
elbow dislocations occur during hyperextension. The majority are posterior
and are obvious clinically and radiographically.

Figure 1.13. Monteggia fractures or dislocations are fractures of the

13. Monteggia fracture proximal ulna with an anterior dislocation of the proximal radius. These injuries
14. Galeazzi fracture (AP) are usually caused by rotational forces, and the dislocation may not be
15. Galeazzi fracture (lateral) obvious. Drawing a radiocapitellar line aids in diagnosis as it demonstrates the
misalignment.

The wrist and hand

tissue and skeletal injury on history and physical examination
Indications alone. Imaging is necessary even with obvious fractures
As with the rest of the upper extremity, the major indication because the extent of the fracture, displacement, angulation,
for imaging of the wrist and hand is with acute trauma. It is and articular involvement are important to determine if
one of the most difficult areas to differentiate between soft the patient needs closed reduction in the ED or immediate 5

09:49:57
01
 Kenny Banh and Gregory W. Hendey

Figure 1.15. Often mistaken for a simple distal radius fracture on AP

Figure 1.14. A Galeazzi fracture, or Piedmont fracture, is a fracture of the
radiograph, the dislocation is clearly evident on a lateral forearm or wrist.
distal third of the radius with dislocation of the distal ulna from the carpal
joints. This is the exact opposite of a Monteggia fracture and is also caused
by rotational forces in the forearm, although more distal.
The minimum standard views of the hand and wrist involve
a posterior-anterior, lateral, and pronated oblique. This third
orthopedic referral for possible open reduction and surgical view helps assess angulated metacarpal fractures that would
fixation. normally superimpose on a true lateral. Accessory views of
There are still settings where imaging of the hand and the hand such as the supination oblique or ball catcher’s view
wrist is not indicated. Carpal tunnel disease and rheumatolo- can help view fractures at the base of the ring and little finger,
gic and gouty disorders are chronic diseases that usually do while a Brewerton view allows better visualization of the
not involve acute trauma and can be diagnosed based on metacarpal bases. The wrist accessory films include
a good history and physical exam alone. a scaphoid view, a carpal tunnel view that looks at the hook
of the hamate and trapezium ridge, and a supination oblique
Diagnostic capabilities view that isolates the pisiform. These accessory films should
be ordered whenever there is localized tenderness or swelling
Besides searching for acute bony fractures and dislocations, in these areas.
plain films can reveal other important pathology. With high- Unlike the proximal upper extremity, fractures in the
pressure injection injuries to the hand, subcutaneous air is wrist and hand may not always be readily apparent on plain
a marker for significant soft tissue injury and is often an films. Scaphoid fractures often result from a FOOSH injury.
indication for surgical exploration. Many carpal dislocations About 10% to 20% of scaphoid fractures have normal radio-
and ligamentous injuries are readily visualized on radio- graphs on initial presentation to the ED (8). Therefore, it is
graphs of the wrist and hand. Perilunate and lunate disloca- extremely important not to disregard these clinical signs of
tions usually result from hyperextension of the wrist and fall scaphoid fracture: “anatomical snuff box” tenderness, pain
on an outstretched hand (FOOSH) injury. They may be with supination against resistance, and pain with axial com-
poorly localized on physical exam and films, and a good pression of the thumb. These signs merit immobilization of
neurovascular exam, especially of the median nerve, is the wrist in a thumb spica splint and follow-up in one to two
indicated. weeks.
More advanced imaging modalities of the wrist and
Imaging pitfalls and limitations hand such as CT, MRI, and high-resolution ultrasound
Because of the size and number of bones, complete radio- are much more sensitive for identifying fractures, bone
graphic sets of hand and wrist films are often acquired. contusions, and ligamentous injury that would be missed
6

09:49:57
01
 Chapter 1: Plain Radiography of the Upper Extremity in Adults

E G
F

H
D
C
A
B
M.D.
S.JOHNSON,

Figure 1.16. A Colles’ fracture occurs at the distal metaphysis of the radius
with dorsal displacement and radial length shortening. An extremely
common injury pattern also seen in FOOSH injuries, the radial head is
Bones of the wrist: palmar view. A = scaphoid, B = lunate, C = triquetrum, D = shortened, creating a disruption of the normally almost linear continuation
pisiform, E = hamate, F = capitate, G = trapezoid, H = trapezium of the radial and ulnar carpal surfaces.

on plain radiography (9). Whether advanced imaging is

indicated in the emergency department may depend on
local resources.

Clinical images
Following are examples of common and important findings in
plain radiography of the wrist and hand:
16. Colles’ fracture (AP)
17. Colles’ fracture (lateral)
18. Smith’s fracture (AP)
19. Smith’s fracture (lateral)
20. Scaphoid fracture
21. Scapholunate dissociation
22. Lunate dislocation (AP)
23. Lunate dislocation (lateral)
24. Perilunate dislocation (AP)
25. Perilunate dislocation (lateral)
26. Boxer’s fracture (AP)
27. Boxer’s fracture (lateral) Figure 1.17. The dorsal displacement is evident on the lateral radiograph,
and proper reduction is needed to restore this alignment.
28. Tuft fracture

09:49:57
01
 Kenny Banh and Gregory W. Hendey

Figure 1.18. A Smith’s fracture, also known as a reverse Colles’ fracture, is

a distal radius fracture with volar instead of dorsal displacement of the hand. Figure 1.19. Sometimes referred to as a “garden spade” deformity, the
Usually caused by direct blows to the dorsum of the hand, these fractures lateral view differentiates this type of fracture from the more common Colles’
often need eventual surgical reduction. fracture.

Figure 1.21. A tight relationship between adjacent carpal bones and the
Figure 1.20. Because of the size and number of hand and wrist bones, many
distal radius and ulna should be observed as well. The loss of this alignment
subtle fractures are missed on cursory views of plain radiographs. All AP hand
or widening of the space, as seen here between the scaphoid and lunate
views should be checked for smooth carpal arches formed by the distal and
bones, is a sign of joint disruption from fracture, dislocation, or joint
proximal bones of the wrist. Evidence of avascular necrosis in scaphoid
instability. A widening of greater than 4 mm is abnormal and known as the
fractures occurs in the proximal body of the fracture because the blood supply
“Terry-Thomas sign” or rotary subluxation of the scaphoid. The scaphoid
of the scaphoid comes distally from a branch of the radial artery. The arrow
8 denotes a scaphoid fracture.
rotates away and has a “signet ring” appearance at times.

09:49:57
01
 Chapter 1: Plain Radiography of the Upper Extremity in Adults

Figure 1.22. Lunate dislocations are the most common dislocations of the Figure 1.23. The lateral view shows the obviously dislocated and tilted
wrist and often occur from FOOSH injuries. They are significant injuries “spilled teacup” lunate. Observe how the capitate and other wrist bones are in
involving a volar displacement and angulation of the lunate bone. Notice how relative alignment with the distal radius.
the carpal arches are no longer clearly seen.

Figure 1.24. Perilunate dislocations are dorsal dislocations of the capitate Figure 1.25. The lateral view of a perilunate dislocation shows the lunate in
and distal wrist bones. Once again, there is a loss of the carpal arcs with alignment with radial head. It is the distal capitate that is obviously displaced,
significant crowding and overlap of the proximal and distal carpal bones. in contrast to the lunate dislocation.
Neurovascular exams for potential median nerve injuries are extremely
important in these injuries. 9

09:49:57
01
 Kenny Banh and Gregory W. Hendey

Figure 1.27. The lateral view reveals the degree of angulation. The amount
of angulation that requires reduction or impairs function of the hand is
controversial, but many believe greater than 30 degrees of angulation requires
reduction (8).

Figure 1.26. Metacarpal neck fracture of the fifth metacarpal, commonly

referred to as a boxer’s fracture, typically occurs from a closed fist striking
a hard object such as a mandible or wall.
References
1. Manthey DE, Storrow AB, Milbourn J, Wagner BJ: Ultrasound
versus radiography in the detection of soft-tissue foreign bodies.
Ann Emerg Med 1996;287–9.
2. Peterson JJ, Bancroft LW, Kransdorf MJ: Wooden foreign
bodies: imaging appearance. AJR Am J Roentgenol 2002;178(3):
557–62.
3. Hendey G, Chally M, Stewart V: Selective radiography in 100
patients with suspected shoulder dislocation. J Emerg Med
2006;31(1):23–8.
4. Hawksworth CR, Freeland P: Inability to fully extend the injured
elbow: an indicator of significant injury. Arch Emerg Med 1991;
8:253.
5. Rabiner JE, Khine H, Avner JR, et al.: Accuracy of point-of-care
ultrasonography for diagnosis of elbow fractures in children.
Ann Emerg Med 2013;61(1):9–17.
6. Hall-Craggs MA, Shorvon PJ: Assessment of the radial
head-capitellum view and the dorsal fat-pad sign in acute elbow
trauma. AJR Am J Roentgenol 1985;145:607.
7. Murphy WA, Siegel MJ: Elbow fat pads with new signs and
extended differential diagnosis. Radiology 1977;124:659.
8. Byrdie A, Raby N: Early MRI in the management of clinical
scaphoid fracture. Brit J Rad 2003;76:296–300.
9. Waeckerle JF: A prospective study identifying the sensitivity of
Figure 1.28. A crush injury to the distal phalanx often causes a tuft
fracture. It is important to evaluate for open fractures, subungual radiographic findings and the efficacy of clinical findings in
hematomas, and concomitant nail bed injury. carpal navicular fractures. Ann Emerg Med 1987;16:733.
10

09:49:57
01
 Lower Extremity Plain Radiography
Chapter

2 Anthony J. Medak, Tudor H. Hughes, and Stephen R. Hayden

Indications calcaneal views as opposed to imaging the entire foot, as this

allows for better visualization of subtle pathology.
Lower extremity injuries are common in ED and urgent care
settings. As part of the workup of these patients, healthcare
providers typically use some type of imaging modality. Plain Imaging pitfalls and limitations
radiography is frequently a starting point, as it is readily
Information obtained from plain radiographs may be limited
available, is inexpensive, and has few contraindications.
by several factors. Most notable is the quality of the technique
In addition, plain radiography involves much lower levels
employed. Penetration of the image and proper patient posi-
of ionizing radiation than CT, for example. The medical
tioning are crucial to obtaining useful images. Improper posi-
literature has discussed at length the long-term risks and
tioning can mask findings of subtle hip, tibial plateau, or foot
effects from ionizing radiation (1). As such, healthcare
and ankle fractures.
providers should give strong consideration to using addi-
Additionally, postoperative patients sometimes pose
tional plain radiograph views (gravity stress, weight bearing,
a challenge. If a patient has had prior surgeries or has an
etc.) rather than automatically opting for other modalities
internal fixation device in place, interpretation of the films
such as CT.
may be difficult. Also, plain radiography itself has inherent
Plain radiography is useful in a number of clinical situa-
limitations, regardless of patient or technique. For example,
tions, including diagnosing fractures and dislocations and
many foreign bodies, including organic material, plastics, and
evaluating the end result after closed reductions performed
some types of glass, are radiolucent and, therefore, not well
in the ED. In addition, it is helpful in evaluating for radio-
visualized with plain radiography. Ultrasound and MRI are
paque foreign bodies and assessing joint spaces for evidence
other imaging options in these cases.
of autoimmune or degenerative processes such as rheumatoid
Plain radiography is very good for evaluating most bony
arthritis or avascular necrosis. Finally, plain films are also
pathology; however, there are exceptions. In the case of osteo-
helpful in evaluating possible infections, including those
myelitis, for example, there is often a delay of 2 to 3 weeks
involving the bone, as in osteomyelitis, or the adjacent soft
between onset of symptoms (pain, fever, swelling) and onset
tissues, as in necrotizing soft tissue infections.
of radiographic findings. As a result, plain radiography alone
is relatively insensitive in diagnosing acute osteomyelitis (2).
Other modalities, including MRI and bone scan, are often
Diagnostic capabilities used in these cases.
Lower extremity radiography is useful for diagnosing frac- Other limitations of plain radiography include failure to
tures and dislocations of the hip, knee, foot, and ankle, as well detect fractures with subtle radiographic findings, such as
as demonstrating pathology of the femur, tibia, and fibula. acetabular, tibial plateau, or midfoot (Lisfranc’s) fractures.
Plain radiography is helpful in evaluating fractures of the In many such instances, CT or MRI is necessary if clinical
lower extremity bones, as well as masses and malignancies, suspicion is high, even in the setting of negative plain films.
including pathological fractures. In some cases, these films It is well reported that, in patients with complex foot and
will be supplemented with CT or MRI of the affected area to ankle fractures, the sensitivity and negative predictive
provide additional information. In addition to bony pathol- value of plain radiography alone are inadequate (3).
ogy, lower extremity radiography is helpful in assessing the In these cases, multidetector CT is the modality of choice.
soft tissues, as in the setting of joint effusions, inflammation of Another area where plain radiography alone yields insuffi-
bursae, soft tissue calcifications, or soft tissue infections. cient anatomical detail is the proximal tibia. Many authors
Finally, plain radiography is also useful for visualizing radio- support supplemental imaging with CT to better delineate
paque foreign bodies of the lower extremity. the anatomy and allow for preoperative planning and frac-
When ordering radiographs of the lower extremity, one ture management (4, 5).
must give careful consideration to selecting the optimal views. Despite these limitations of lower extremity radiography,
Obtaining the proper radiographic views will significantly some simple measures may be taken to improve overall diag-
affect the utility of the study. For example, when looking for nostic accuracy. As noted previously, proper image penetra- 11
calcaneal pathology, it is advisable to obtain dedicated tion and patient positioning are imperative. Beyond this, the

09:51:30
02
 Anthony J. Medak, Tudor H. Hughes, and Stephen R. Hayden

Figure 2.2. Open anterior fracture-dislocation of hip. An AP radiograph

shows the left hip to be dislocated with the femoral head inferior, compatible
with anterior dislocation. The leg is abducted and externally rotated, which is
commonly the leg position that predisposes to anterior dislocation.
In addition, note the acetabular fracture on the right.

Figure 2.1. Anterior hip fracture-dislocation. The initial AP radiograph (A)

shows the right leg to be externally rotated and the superior acetabulum to
have a discontinuous margin due to an accompanying acetabular fracture.
The CT scans, both axial (B) and 3D reconstructions (C), show the anterior
dislocation of the femur, with both acetabular fracture and impaction fracture
of the femoral head.

use of stress imaging, whether it be weight bearing (to

enhance Lisfranc injury) or gravity stress (to enhance ankle
instability), can be very useful (6, 7). Stress views can reveal
much more about the function of ligaments and as such are
often superior and complementary to MRI.
Finally, as with any radiographic imaging, one must have
sufficient knowledge of the normal anatomy to be able to
recognize pathology. This includes the ability to distinguish
normal variants from true pathology. For example, bipartite Figure 2.3. Posterior hip dislocation. AP (A) and lateral (B) radiographs of
a 15-year-old male with a posterior left hip dislocation. Note the high position
patella, presence of a growth plate, or sesamoid bone may all of the left femoral head on the AP view and the posterior position on the
be mistaken for abnormalities if a basic understanding of lateral view, which is projecting supine with the ischium (a posterior structure)
normal anatomy is lacking. at the bottom of the image (arrow).
12

09:51:30
02
 Chapter 2: Lower Extremity Plain Radiography

Figure 2.4. Acetabular fracture not well visualized on CT. This 19-year-old male sustained a horizontal fracture of the right acetabulum in a motor vehicle
collision. The AP view (A) shows the fracture line over the medial acetabulum, and the Judet views (B, C), RPO (right posterior oblique), and LPO (left posterior
oblique) show the involvement of the posterior column and anterior column, respectively (arrows). This fracture was very difficult to see on CT due to the fracture
plane being the same as that of the axial CT images. This underscores the importance, in some cases, of multiple imaging modalities to properly characterize the
injury.

13

09:51:30
02
 Anthony J. Medak, Tudor H. Hughes, and Stephen R. Hayden

Figure 2.5. Posttraumatic avascular necrosis (AVN). This 17-year-old male sustained a femoral neck fracture (A). Four years later following decompression, the
subsequent radiograph (B), as well as the coronal plane T1-weighted MRI (C), show sclerosis and lucencies on the radiograph (arrows) and well-defined margins of
AVN on the MRI (arrow).

14

09:51:30
02
 Chapter 2: Lower Extremity Plain Radiography

Figure 2.6. Impacted fracture of right femoral neck. An AP radiograph shows Figure 2.8. Horizontal intertrochanteric fracture. The left posterior oblique
impaction of the lateral femoral neck as well as a band of sclerosis (arrows) in radiograph of the pelvis shows a relatively horizontal intertrochanteric
this 46-year-old male. fracture. Most fractures in this region are more oblique from superolateral to
inferomedial.

Figure 2.7. Greater trochanter fracture. This 68-year-old female sustained a greater trochanter fracture, difficult to appreciate with plain radiography (A).
The subsequent coronal T2-weighted MRI (B) shows the edema in the greater trochanter and adjacent hip abductors (arrows). MRI is useful in the differentiation of
surgical and nonsurgical management.

15

09:51:30
02
 Anthony J. Medak, Tudor H. Hughes, and Stephen R. Hayden

Figure 2.9. Pathological fracture of the left subtrochanteric femur. AP radiograph of the left hip in this
70-year-old male with Paget disease shows abnormal architecture of the proximal femur with a coarse
trabecular pattern and cortical thickening typical of the sclerotic phase of this disease. A pathological
fracture has occurred through the weakened abnormal bone.

Figure 2.10. Dislocated total hip arthroplasty. AP and lateral views of the right hip with anterior dislocation (A, B) (the ring represents the femoral head) and
following reduction (C, D). Note the femoral head must be concentric with the acetabulum on both views for it to be correctly located.

16

09:51:30
02
 Chapter 2: Lower Extremity Plain Radiography

Figure 2.12. Subluxed patella. A bilateral Merchant view of the patellae

shows the right patella to be laterally subluxed. Axial views of the patella are
taken with the knees flexed 40 degrees and with the film either on the shins
(Merchant projection) or on the thighs (Inferosuperior projection).

Figure 2.13. Bipartite patella. AP (A) and axial (B) views of the left knee in
Figure 2.11. Giant cell tumor of bone involving the right distal femur. a 16-year-old male. Note that the accessory bone fragment is always
AP (A) and lateral (B) radiographs in a 37-year-old male show a lytic lesion superolateral. The margins are rounded and sclerotic, excluding an acute
involving the metaphysis and extending to the epiphysis (arrows). It has fracture.
a mixed benign and aggressive appearance, with the lateral margin being
well defined and the proximal margin more ill defined.

17

09:51:30
02
 Anthony J. Medak, Tudor H. Hughes, and Stephen R. Hayden

Figure 2.14. Patella alta. AP (A) and lateral (B) radiographs in a 55-year-old male show the patella to be in a higher location than is normal. The distance from the
inferior articular surface of the patella to the tibial tubercle should be between 1.5 and 2 times the length of the articular surface of the patella.

18 Figure 2.15. Femoral condyle fracture. AP (A) and lateral (B) radiographs of the left knee in a 37-year-old male show a coronal oblique fracture of the lateral
femoral condyle. Sagittal plane condylar fractures are more common than coronal. Coronal fractures tend to occur on the lateral side and are called Hoffa fractures.

09:51:30
02
 Chapter 2: Lower Extremity Plain Radiography

Figure 2.16. Knee dislocation. AP (A) and lateral (B) radiographs in a 77-year-old female show a knee dislocation. The subsequent postreduction angiogram (C)
shows abrupt disruption of flow in the popliteal artery (arrow). Arterial injury is one of the major concerns in a patient with knee dislocation.

19

09:51:30
02
 Anthony J. Medak, Tudor H. Hughes, and Stephen R. Hayden

Figure 2.17. Tibial plateau fracture. AP (A) and lateral (B) radiographs in a 24-year-old female following trauma show irregularity of the lateral tibial plateau
with a band of sclerosis between the subchondral bone plate and the epiphyseal scar (arrows). The oblique view (C) confirms this finding (arrows) and is often
helpful in equivocal cases in the absence of CT. The CT images with coronal (D) and axial (E) reformations also confirm the impacted lateral tibial plateau fracture
(arrows). CT is much more sensitive in detecting tibial plateau fractures than is plain radiography, and it is often used for preoperative planning and management
decisions.

20

09:51:30
02
Figure 2.18. Tibial spine avulsion. AP (A) and lateral (B) radiographs in a 58-year-old male show avulsion of the tibial spines by the anterior cruciate ligament
(arrow). The subsequent coronal T1-weighted MRI (C) confirms this finding (arrow). Due to the comparative strengths of ligaments and bones, this injury is more
common in children, whereas ACL tears are more common in adults.

Figure 2.19. Knee lipohemarthrosis. AP (A)

and lateral (B) radiographs in a 51-year-old
female show a vertical split fracture of the
lateral tibial plateau. In addition, the lateral
recumbent view (C) shows a large joint
effusion/hemarthrosis. The cross-table lateral
view taken with a horizontal beam (C) shows
a fat fluid level (lipohemarthrosis) within the
knee (arrows). The fat is released from the
bone marrow, confirming the intra-articular
fracture. In some cases, this may be the only
finding on plain radiography to suggest
a fracture.

21

09:51:30
02
 Anthony J. Medak, Tudor H. Hughes, and Stephen R. Hayden

A B

Figure 2.20. AP close-up radiograph of the lateral aspect of the left knee (A) in a 34-year-old man following trauma, shows a small bone fragment projecting over
the lateral aspect of the proximal tibia and fibula (arrowheads). This represents a Segond fracture avulsion by the lateral capsular ligamentous complex and is
a strong indicator of an ACL tear. The ACL injury (arrow) is shown in the accompanying sagittal proton density fat saturated MRI through the midline of the
intercondylar notch of the same knee (B). Note that the rounded bone more superiorly overlying the lateral margin of the distal femur on the radiograph (arrow) is
a normal variant, the fabella.

Figure 2.21. Large knee joint effusion. Lateral radiograph of the knee shows
a bulging soft tissue density arising from the superior aspect of the patellofemoral
joint due to an effusion. If the lateral knee radiograph is obtained flexed more than
30 degrees, an effusion may be pushed posteriorly so that it is no longer visible.

22

09:51:30
02
 Chapter 2: Lower Extremity Plain Radiography

Figure 2.22. Osteoarthrosis of the knee. AP (A) and lateral (B) radiographs of the right knee in a 52-year-old male show the four cardinal signs of osteoarthrosis:
1) focal joint space narrowing, 2) subchondral sclerosis, 3) subchondral cysts, and 4) osteophytes. In addition, a large intra-articular body is seen in the popliteal recess
(arrow).

A B

Figure 2.23. AP radiographs of the right knee in a 71-year-old female with severe osteoarthrosis. Although the non-weight-bearing view (A) shows severe
medial compartment joint space narrowing, it is only with weight bearing (B) that the full extent of the accompanying genu varum deformity becomes apparent.
This will likely affect the arthroplasty technique selected for definitive treatment.
23

09:51:30
02
 Anthony J. Medak, Tudor H. Hughes, and Stephen R. Hayden

Figure 2.24. Fabella. AP (A) and lateral (B) radiographs of the knee of a 35-year-old male demonstrate a fabella, a sesamoid bone within the lateral head of the
gastrocnemius muscle (arrows). The fabella is sometimes mistaken for an intra-articular ossified fragment. Note that the fabella is always lateral. In AP projection,
the fabella is round. In the lateral view, the anterior margin should be flat or concave.

Figure 2.25. Metal synovitis of the knee. Lateral oblique radiograph (A), with coned down view (B), in a 69-year-old female who has extensive
microfragmentation of a total knee arthroplasty. Metal has collected in the synovium, producing a synovitis.

24

09:51:30
02
 Figure 2.26. Acute osteomyelitis. AP radiograph of the proximal tibia shows an ill-defined
lucency with periosteal reaction, compatible with an aggressive process – in this case,
osteomyelitis.

Figure 2.27. Osteosarcoma. AP (A) and lateral (B)

radiographs of the right proximal tibia in a 16-year-
old male show an ill-defined but dense area of
sclerosis in the lateral proximal tibia. Coronal (C) and
axial (D) T1-weighted MRI show low signal centrally,
compatible with bone formation, and high signal
peripherally, compatible with gadolinium uptake by
growing tumor.

25

09:51:30
02
 Anthony J. Medak, Tudor H. Hughes, and Stephen R. Hayden

Figure 2.28. Tibial fracture. AP (A) and lateral (B) radiographs of a 16-year-old Figure 2.29. Toddler fracture. AP radiograph of a 22-month-old boy, whose
male following trauma. The AP view clearly shows the steep oblique fracture of leg became trapped beneath his mother while descending a slide, shows
the midtibial shaft. Note the difficulty of seeing the fracture on the lateral view, a spiral fracture of the distal tibia (arrows). These nondisplaced toddler
emphasizing the need for more than one view to assess trauma. fractures are often difficult to see on radiographs acutely.

Figure 2.30. Fibular shaft fracture. AP (A) and lateral (B) radiographs of the Figure 2.31. Ankle effusion. Lateral radiograph of the ankle in a 25-year-old
26 tibia and fibula in a 45-year-old male following pedestrian versus auto male with chronic renal failure. Anterior to the ankle joint is a moderate-size
accident. The fracture of the midshaft of the fibula has a butterfly fragment, effusion. When such a dense effusion is noted, presence of hemarthrosis must
which is strongly associated with direct trauma. be considered.

09:51:30
02
 Chapter 2: Lower Extremity Plain Radiography

Figure 2.32. Maisonneuve fracture. Mortise (A) and lateral (B) projections of the left ankle in a 54-year-old male show a transverse fracture of medial malleolus
(arrow in Fig. 2.32A), extending to involve the posterior malleolus (arrow in Fig. 2.32B). In this situation, especially if the distal tibiofibular space is widened, views of
the proximal tibia and fibula (C) are recommended to look for a proximal Maisonneuve fracture of the fibula (arrow in Fig. 2.32C).

Figure 2.33. Lateral malleolus fracture. Mortise (A) and lateral (B) views of the Figure 2.34. Wide medial and syndesmotic clear spaces. AP (A) and mortise
left ankle show a fracture line passing from superoposterior to anteroinferior (B) views of the left ankle in a 34-year-old male following a twisting injury.
on the lateral view (arrow), which is difficult to see on the mortise view. This is The ankle is incongruent, with the medial aspect of the joint wider than the
a very common pattern of ankle fracture and emphasizes the need to look superior joint space (arrow), indicating a medial ligament injury. In addition, the
carefully at the lateral view. distal tibiofibular clear space is too wide. In this setting, views of the proximal
fibula are recommended to evaluate for a Maisonneuve fracture (see Fig. 2.32).
27

09:51:30
02
 Anthony J. Medak, Tudor H. Hughes, and Stephen R. Hayden

Figure 2.35. Medial and posterior malleolar fractures. AP (A), mortise (B), and lateral (C) views of the right ankle in an 18-year-old male show a medial malleolar
fracture (arrow in Fig. 2.35B) that extends around to the posterior malleolus (arrow in Fig. 2.35C). Posterior malleolar fractures appear on the AP and mortise views as
an inverted V–shaped lucent line. On the lateral view, it is important to discern whether the fracture is of the lateral malleolus or posterior malleolus.

28

09:51:30
02
 Chapter 2: Lower Extremity Plain Radiography

A B

Figure 2.36. Frontal radiographs of the right ankle in a 48-year-old woman, without (A) and with (B) gravity stress. The stress views show widening of the medial
mortise (arrow) compatible with a deltoid ligament injury. This upgrades the Lauge Hansen “supination external rotation” injury from a stable grade 2 to an
unstable grade 4.

29

09:51:30
02
 Anthony J. Medak, Tudor H. Hughes, and Stephen R. Hayden

Figure 2.37. Tibial plafond fracture. Sagittal (A), coronal (B), and 3D reformations (C) of the distal tibia in a 35-year-old male following an all-terrain vehicle rollover
accident. The tibial plafond is grossly comminuted, and the fractures have a vertical configuration compatible with a pilon-type fracture.

30

09:51:30
02
 Chapter 2: Lower Extremity Plain Radiography

Figure 2.38. Ankle dislocation. Lateral (A) and oblique (B) radiographs of the left foot/ankle in a 59-year-old male show an open dislocation of the ankle, with gas
seen within the joint (arrows).

Figure 2.39. Ankle fracture-dislocation. Lateral (A) and oblique (B) radiographs of the right ankle show an ankle fracture-dislocation. On finding an obvious
fracture such as this, it is important not to stop looking for the less obvious fracture, in this case, at the base of the fifth metatarsal (arrow in Fig. 2.39A).

31

09:51:30
02
 Anthony J. Medak, Tudor H. Hughes, and Stephen R. Hayden

Figure 2.40. Calcaneal fracture. Lateral (A) and axial (Harris-Beath) radiographs (B) of the left heel in a 26-year-old male following a fall. The fracture of the anterior
and medial calcaneus can be visualized on both views (arrows), with the axial view showing involvement at the base of the sustentaculum talus.

Figure 2.41. Calcaneal fracture. Lateral (A) and axial (Harris-Beath) radiographs (B) and coronal oblique CT (C) in a 44-year-old male with a calcaneal fracture
following a fall. The lateral view is used to measure Boehler’s angle. A line is drawn from the superior margin of the posterior tuberosity of the calcaneus, extending
through the superior tip of the posterior facet (line 1), and another line from this latter point, extending through the superior tip of the anterior process (line 2).
The angle made by the intersection of these lines should normally be between 20 and 40 degrees. When less than 20 degrees, this implies an intra-articular,
impacted fracture. The axial view (B) and CT (C) clearly show the inverted Y configuration of the fractures that is a common pattern and the involvement of the
posterior subtalar joint.

32

09:51:30
02
 Chapter 2: Lower Extremity Plain Radiography

Figure 2.42. Avulsion fracture of base of fifth metatarsal. Oblique (A) and Figure 2.43. Dancer’s fracture. PA (A) and lateral (B) radiographs of the right
lateral (B) radiographs of the right foot in a skeletally immature patient show foot in a 46-year-old female show a spiral fracture of the distal shaft of the fifth
the transverse fracture superimposed on the open apophysis (arrow). metatarsal, known as a dancer’s fracture (arrows).

Figure 2.44. Jones fracture. PA (A) and lateral (B) radiographs of the right foot in a 33-year-old male show an extra-articular fracture of the proximal fifth
metatarsal, known as a Jones fracture (arrows). Note that this fracture is distinctly different from the more common avulsion fracture of the fifth metatarsal 33
tuberosity (see Fig. 2.42). Patients with the avulsion injury generally do well; however, the Jones fracture may result in nonunion and require surgical repair.

09:51:30
02
 Anthony J. Medak, Tudor H. Hughes, and Stephen R. Hayden

Figure 2.45. Metatarsal stress fracture. PA (A) and oblique coned down (B) radiographs of the left forefoot in a 48-year-old male show a fusiform periosteal
reaction of the distal second metatarsal shaft/neck (arrows). This is typical of a stress fracture, if a fracture line can be seen, or may be called a stress reaction if the
fracture line is not visualized. These may be very subtle and must be sought to be recognized.

Figure 2.46. Lisfranc fracture subluxation. PA radiograph (A) of the right foot in
a 23-year-old male shows malalignment at the medial tarsometatarsal joints
(arrowhead) and a fracture at the base of the second metatarsal (arrow). As a rule,
the medial side of the second metatarsal should always line up with the medial
side of the middle cuneiform as illustrated (B).

Normal AP Right Foot: A = Medial cuneiform, B = Intermediate

cuneiform, C = Lateral cuneiform, D = Cuboid, E = Navicular,
F = Talus, G = Calcaneus

34

09:51:30
02
 Chapter 2: Lower Extremity Plain Radiography

Figure 2.49. Soft tissue gas in an infected foot. PA (A) and lateral (B)
radiographs of the left foot in a 65-year-old diabetic male show extensive gas
within the soft tissues on the lateral side of the forefoot (arrows). A careful
inspection of the bones for ill-defined erosion is needed to exclude
osteomyelitis.

Figure 2.47. Lisfranc fracture subluxation. Three views of the foot of a 19-
year-old male reveal another example of a Lisfranc fracture subluxation. PA
view (A) demonstrates the lack of normal alignment between the medial
margin of the second metatarsal with the medial margin of the middle
cuneiform (arrow). Lateral projection (B) reveals a slight dorsal displacement of
the metatarsals on the cuneiforms (arrow). Oblique view (C) illustrates the lack
of normal alignment between the medial margin of the fourth metatarsal and
the medial margin of the cuboid (contrast with illustration in Fig. 2.46B).

A B

Figure 2.48. Lateral radiographs of the right foot in a 31-year-old woman with a chronic Lisfranc injury. Although a slight step is seen on the dorsal aspect of the
middle cuneiform-second metatarsal joint, with the metatarsal displaced dorsally on the non-weight-bearing view (A), this becomes much more apparent and is
accentuated by weight bearing (B), greatly aiding in this often difficult diagnosis (arrows).
35

09:51:30
02
 Anthony J. Medak, Tudor H. Hughes, and Stephen R. Hayden

A B

Figure 2.50. AP (A) and lateral (B) radiographs of the great toe in a 70-year-old man with diabetes and clinically dry gangrene of the great toe. The numerous
small low densities represent soft tissue gas and are worrisome for gas gangrene, a more fulminant infection.

Figure 2.51. Radiopaque foreign body. Radiographs of the right great toe in a 13-year-old boy show a barbed fish hook in the dorsal soft tissues.

36

09:51:30
02
 Chapter 2: Lower Extremity Plain Radiography

A B

Figure 2.52. AP (A) and oblique (B) radiographs of the lateral forefoot in a 54-year-old man with diabetes. The sharp angular object of increased density adjacent
to the fifth PIP joint is a shard of glass. There is accompanying gas in the soft tissue. Note how using two views of the affected area allows for localization of the glass
to the plantar aspect of the foot.

Figure 2.53. Radiolucent foreign body. Ultrasound of the dorsal soft tissues Figure 2.54. Osteomyelitis. Oblique coned down radiograph of the lateral
of the foot reveals a wooden (radiolucent, not visible on x-ray) foreign body forefoot in a 33-year-old male with diabetes shows extensive bony destruction
between the markers (arrows). It is hyperechoic (bright) on ultrasound and of the fifth ray, centered at the metatarsal-phalangeal joint, and periosteal
casts an acoustic shadow because so much of the incident sound is reflected
back by the body that little passes through to the deeper tissues.
reactions (arrows) of the fourth and fifth metatarsal bones due to osteomyelitis. 37

09:51:30
02
 Anthony J. Medak, Tudor H. Hughes, and Stephen R. Hayden

A B

Figure 2.55. AP radiographs of the left foot of a 61-year-old female, without and with weight bearing. Although the non-weight-bearing view (A) shows the
hallux valgus and first MTP joint osteoarthrosis, it is only with weight bearing (B) that the second MTP joint dislocation occurs and the degree of hallux valgus
increases.

Figure 2.56. Open fifth metatarsal apophyseal growth plate. Oblique (A) and
lateral (B) radiographs of the left foot in a skeletally immature patient show the
orientation of the fifth metatarsal growth plate. Note how this mimics a fifth
metatarsal avulsion fracture.

38

09:51:30
02
 Chapter 2: Lower Extremity Plain Radiography

Figure 2.57. Rheumatoid arthritis. PA radiographs of both feet in a 43-year-old female show typical changes of rheumatoid arthritis. Note that the erosions of the
metatarsal-phalangeal joints are symmetric.

Figure 2.58. Gout. Oblique radiograph of the left foot (A) with a coned down view (B) of the first metatarsalphalangeal joint in a 53-year-old male with gout show
eccentric soft tissue swelling (arrows) and well-defined erosions with overhanging edges but relative preservation of joint space.

39

09:51:30
02
 Anthony J. Medak, Tudor H. Hughes, and Stephen R. Hayden

References comparison with conventional radiography. Acta Radiol 2005;46

(8):866–74.
1. Brenner DJ, Hall EJ: Computed tomography: an increasing source 5. Wicky S, Blaser PF, Blanc CH, et al.: Comparison between
of radiation exposure. N Engl J Med 2007;357(22):2277–84. standard radiography and spiral CT with 3D reconstruction in
2. Gold RH, Hawkins RA, Katz RD: Bacterial osteomyelitis: the evaluation, classification and management of tibial plateau
findings on plain radiography, CT, MR, and scintigraphy. AJR fractures. Eur Radiol 2000;10(8):1227–32.
Am J Roentgenol 1991;157:365–70. 6. Gupta RT, Wadhwa RP, Learch TJ, Herwick SM: Lisfranc injury:
3. Haapamaki VV, Kiuru MJ, Koskinen SK: Ankle and foot injuries: imaging findings for this important but often-missed diagnosis.
analysis of MDCT findings. AJR Am J Roentgenol 2004;183(3): Curr Probl Diagn Radiol 2008;37(3):115–26.
615–22. 7. McConnell T, Creevy W, Tornetta III P: Stress examination of
4. Mustonen AO, Koskinen SK, Kiuru MJ: Acute knee trauma: supination external rotation-type fibular fractures. J Bone Joint
analysis of multidetector computed tomography findings and Surg Am 2004;86-A(10):2171–8.

40

09:51:30
02
 Chest Radiograph
Chapter

3 Peter DeBlieux and Lisa Mills

Indications In thoracic trauma, CXR evaluates for multiple bony and

soft tissue injuries. CXR is the screening exam for thoracic
The chest radiograph (CXR) is the most commonly ordered
aortic injury, pulmonary contusion, pneumothorax,
plain film in emergency medicine and has correspondingly
hemothorax, and traumatic pericardial effusion. Skeletal inju-
broad indications. It is ordered to evaluate patients with chest
ries – including rib, scapular, clavicular, shoulder, and sternal
pain, breathing complaints, thorax trauma, fevers, and altered
fractures and dislocations – can be seen on CXR.
mental status. Patients who complain of chest pain have
a broad differential diagnosis, and CXR is one of the first
screening tests to be applied in chest pain complaints. This Imaging pitfalls and limitations
study is relevant when cardiac or pulmonary processes are The most significant limitation of CXR is obtaining
suspected. CXR should be obtained when patients are sus- a limited number of studies. This is particularly true when
pected of having an occult infectious process, a fever, altered only a supine film is obtained. In supine films, small collec-
mental status, or hypotension. A screening CXR also helps tions of pleural fluid and small pneumothoraces are missed
initially evaluate patients for thoracic injury after thoracoab- because these layer out along the lungs, rather than at the
dominal trauma. base or apex of the lung. The anteroposterior technique
artificially enlarges the cardiomediastinal silhouette. Rib
Diagnostic capabilities fractures, especially along the angle of the ribs, are difficult
to see on a standard two-view chest series. Oblique views
CXR is useful to diagnose or identify primary cardiac and
enhance the sensitivity of CXR for rib fractures. CXR iden-
pulmonary pathology, abnormal pleural processes, thoracic
tifies lung masses, pleural lesions, air-space disease, and
aortic dilation, aspirated foreign bodies, and thoracic
hilar masses. However, CT better delineates the quality of
trauma. In cardiac disease, the CXR reveals pulmonary
these lesions.
edema, moderate to large pericardial effusion, and cardio-
megaly. CXR shows multiple primary pulmonary processes.
It reveals infectious processes, such as lobar pneumonia, Systematic approach to reading the CXR
tuberculosis, atypical pneumonia, empyema, and lung A consistent approach to the CXR improves detection of
abscess. Pulmonary processes such as pneumonitis, hyper- pathology. The authors promote an alphabetical approach,
aeration due to chronic obstructive pulmonary disease A to F:
(COPD) and asthma, and lung masses are evident on A = airway
CXR. Pleural processes such as pleural thickening, pneu- B = bones
mothorax, hemothorax, and pleural effusions are also evi-
C = cardiomediastinum
dent on CXR. CXR is the first radiologic screening test for
thoracic aneurysm. The anteroposterior upright CXR D = diaphragms
shows 90% sensitivity for thoracic aneurysm, when any E = everything else (pleura, soft tissue, visualized portions
abnormality is considered a positive test (1). When aspi- of the abdomen)
rated foreign body is suspected, a CXR can reveal the loca- F = lung fields
tion of radiopaque foreign bodies whether in the trachea, See the normal posteroanterior (PA) and lateral CXR in
smaller airways, esophagus, or stomach. Figure 3.1 for a demonstration of this technique.

41

09:52:49
03
 Peter DeBlieux and Lisa Mills

Clinical images

Figure 3.1. Normal PA and lateral. Airway: A good inspiratory film should reveal the diaphragm at the level of the eighth to tenth posterior ribs or the fifth to sixth
anterior ribs. The trachea should be visible in the midline of the thoracic cavity equidistant between the clavicular heads. In the anteroposterior and
posteroanterior views, the right paratracheal stripe is usually 2 to 3 mm wide, 5 mm being the upper limit of normal. On a lateral CXR, the posterior tracheal wall
should be less than 4 mm wide. The trachea should smoothly divide at the carina with both major bronchi visible.
Bones: Examine the bones for lytic or blastic lesions, fractures, spinal alignment, and joint spaces. The thoracic spine should decrease in opacity (brightness) as it is
followed inferiorly (caudally). An area of increased opacity suggests an overlying density in the lung. This is termed the “spine sign.”
Cardiomediastinum: Examine the mediastinum for size and deviation. The trachea and aorta course down the middle of the thoracic cavity without significant
deviation to either side. The aortic arch and knob should be visible. The widest diameter of the heart should be less than 50% of the widest diameter of the thoracic
cavity, measured from the inner aspects of the ribs. Look for air lines to suggest pneumopericardium or pneumomediastinum. The aortic knob is the first “bump” of
the mediastinum, lying in the left hemithorax. The left pulmonary artery is below the aortic knob separated by a small clear space called the “aortopulmonary
window.” The right pulmonary artery is usually hidden from visualization by the mediastinum. Behind the sternum, superior to the heart, is the anterior clear space.
This should be the density of lung tissue. Soft tissue density suggests infiltrate or mass.
Diaphragms: Follow the mediastinum to the diaphragms. Follow the diaphragms, looking for a smooth course to the costophrenic angles and sharp
costophrenic angles. Check for free air under the diaphragms. Both diaphragms should be seen in the lateral view, with the right diaphragm usually higher than
the left, with a gastric bubble below.
Everything else: Follow the pleural lines from the costophrenic angles to the apex and around the mediastinum back to the diaphragms. Look for areas of
thickening or separation from the chest wall. Check the visualized soft tissues for calcifications, mass effect, and air collections (subcutaneous emphysema).
Examine the visualized portion of the abdomen.
Lung fields: The right lung is approximately 55% of the intrathoracic volume. The left lung is 45%. If these ratios change, consider hyperinflation or atelectasis in
one hemithorax. Follow vascular patterns for signs of congestion or oligemia. Look for opacities and hyperlucent areas.

42

09:52:49
03
 Chapter 3: Chest Radiograph

Figure 3.3. Normal supine. In the supine patient, the mediastinum is not
stretched toward the feet by gravity. The result is crowding of the mediastinal
features, giving the appearance of a larger mediastinum and larger transverse
diameter of the cardiac silhouette.

Figure 3.4. Normal anterosterior. This radiograph is usually taken as a portable study. The film cartridge is at the patient’s back, and the patient is exposed
from the front to the back. (This is the opposite of the PA, in which the patient faces the cartridge, and the back is exposed first.) The heart is artificially magnified,
giving the appearance that the heart is larger than posterior structures. In addition, the structures in the thorax are more crowded as the patient remains
seated. This causes vascular crowding. These inherent findings should be kept in mind when interpreting these films.

Figure 3.6. Normal infant. The normal infant has an enlarged

Figure 3.5. Normal apical. The apical view of the lungs focuses on the lung
cardiomediastinal silhouette due to the thymus extending into the thoracic
apices. The patient is positioned so the clavicles and ribs are moved away from
cavity.
the apices of the lung.

43

09:52:49
03
Other documents randomly have
different content
The Project Gutenberg eBook of Brigadier
Frederick; and, The Dean's Watch
This ebook is for the use of anyone anywhere in the United
States and most other parts of the world at no cost and with
almost no restrictions whatsoever. You may copy it, give it away
or re-use it under the terms of the Project Gutenberg License
included with this ebook or online at www.gutenberg.org. If you
are not located in the United States, you will have to check the
laws of the country where you are located before using this
eBook.

Title: Brigadier Frederick; and, The Dean's Watch

Creator: Erckmann-Chatrian

Translator: Richard Burton

Release date: October 11, 2015 [eBook #50186]

Language: English

Credits: Produced by Al Haines

*** START OF THE PROJECT GUTENBERG EBOOK BRIGADIER

FREDERICK; AND, THE DEAN'S WATCH ***
Emile Erckmann
 Title page

ERCKMANN-CHATRIAN
Brigadier Frederick
AND
The Dean's Watch
 TRANSLATED FROM THE FRENCH
WITH A CRITICAL INTRODUCTION
BY PROF. RICHARD BURTON, OF THE
UNIVERSITY OF MINNESOTA
A FRONTISPIECE AND NUMEROUS
OTHER PORTRAITS WITH
DESCRIPTIVE NOTES BY
OCTAVE UZANNE

P. F. COLLIER & SON

NEW YORK

COPYRIGHT, 1902
BY D. APPLETON & COMPANY

ERCKMANN-CHATRIAN

Fashions change in literature, but certain things abide. There may be

disputes from generation to generation, even from decade to
decade, as to what is æsthetic, or what is beautiful; there is less as
to what is human. The work of the French writers, whose duality is
quite lost in the long-time association of their names for the
purposes of story making, seems at the least to make this claim to
outlast its authors: it is delightfully saturated with humanity.
And this humanity is of the sort that, since it can be understood
of all men, is therefore very widely acceptable. It is well to
emphasize the point in an attempt to explain the popularity of
Erckmann-Chatrian, immediate or remote. There are other reasons,
to be sure: but this one is at the door, knocking to be heard. But to
speak of the essential humanity of these books is not to deny or
ignore their art; that they have in abundance--quite as truly indeed
as the work of your most insistent advocate of "art for art"; but it is
art for life's sake. In the best sense, the verisimilitude of the
Erckmann-Chatrian stories is admirable, impressive. They are, as a
rule, exquisitely in key. They produce a cumulative effect by steadily,
unobtrusively clinging to a single view-point, that of the speaker who
is an eye-witness, and the result is a double charm--that of reality
and that of illusion. One sees life, not through the eyes of the
authors, but through the eyes of the characters; hence the frequent
setting-forth of principles is relieved from didacticism by the careful
way in which the writers refrain from expressing their own opinion.
So artistic are they that they even indulge in the delicate ruse of
opposing the views which are really their own, thereby producing a
still stronger effect of fair-mindedness and detachment.
Yet, as the world knows, in the most justly famed of their
books, the so-called National Novels, it is their purpose to preach
against war; they are early advocates of the principles of the Peace
Congress at The Hague, forerunners, in their own fashion, of the
ideas expressed in art and literature by later men like Tolstoy and
Verestchagin.
 The local colour--one still uses the phrase as convenient--is
remarkable for its sympathetic fidelity; the style well-nigh a model of
prose whose purpose it is to depict in homely yet picturesque terms
the passage of great events, seen by humble, it may be Philistine,
folk, and hence not seen couleur de rose. When a heartfelt
sympathy for average human-kind rises to the surface of the
author's feeling, some candid, cordial phrase is ever found to
express it.
The work of Erckmann-Chatrian, voluminous as it is, can be
easily classified: it mainly consists of the idyl and the picture of war;
L'lllustre Docteur Mathéus, their first success, happily illustrates the
former genre; any one of the half dozen tales making up the
National Novel series may be taken to represent the latter. Both
veins turned out to be gold mines, so rich were they in the free-
milling ore of popular favour. Such stories as L'Ami Fritz and The
Brigadier Frederick are types of the two kinds of fiction which
panned out most richly also for the world. In the idyl dealing with
homely provincial life--the life of their home province--these authors
are, of a truth, masters. The story is naught, the way of telling it, all
that breeds atmosphere and innuendo, is everything. In L'Ami Fritz
the plot may be told in a sentence: 'tis the wooing and winning of a
country lass, daughter of a farmer, by a well-to-do jovial bachelor of
middle age in a small town; voilà tout; yet the tale makes not only
delicious reading, it leaves a permanent impression of pleasure--one
is fain to re-read it. It is rich in human nature, in a comfortable
sense of the good things of the earth; food and drink, soft beds,
one's seat at the tavern, spring sunlight, and the sound of a fiddle
playing dance tunes at the fair: and, on a higher plane, of the genial
joys of comradeship and the stanch belief in one's native land. When
the subtler passion of love comes in upon this simple pastoral scene,
the gradual discovery of Friend Fritz that the sentiment he has
always ridiculed has him at last in its clutch, is portrayed with a sly
unction, a kindly humour overlying an unmistakable tenderness of
heart, which give the tale great charm. Sweetness and soundness
are fundamentals of such literature.
This tale is a type of them all, though deservedly the best liked.
Love of nature and of human nature, a knowledge of the little,
significant things that make up life, an exquisite realism along with a
sort of temperamental optimism which assumes good of men and
women—these blend in the provincial stories in such a way that
one's sense of art is charmed while in no less degree one's sense of
life is quickened and comforted. Erckmann-Chatrian introduced to
French readers the genuine Alsatian, not the puppet of the
vaudeville stage. Their books are, among other things, historical
documents. From their sketches and tales better than in any other
way one can gain an understanding of the present German provinces
of Alsace and Lorraine during a period stretching from the Revolution
to and after the Franco-Prussian war. The Alsatian in their hands is
seen distinctly as one of the most interesting of Gallic provincial
types.
The attitude of Dr. Mathéus, that charming physician savant,
who is in love with science, with the great world of scholarship and
literary fame, and so is fain to leave his simple countryside in quest
of renown—in his final return to his home as, after all, the best spot
on earth, typifies the teaching of these authors in all their works.
The tale is a sort of allegory, veiling a sermon on the value of the
"fireside clime" of home hearths and hearts. Nor must it be forgotten
that these writers cultivated the short story or tale with vigour and
success; The Dean's Watch, printed in the present volume, is an
excellent example of the genre. Erckmann-Chatrian, especially in the
earlier years of their conjoined labour, wrote numerous pieces of
short fiction which abounded in gruesome adventure and situations
more or less startling—witness the Heidelberg murder story. They
possessed a considerable talent for the detective fiction brought to a
fine art by Poe and worthily carried on in our day by Conan Doyle.
Yet even here the work has a higher value—perhaps the highest—for
the thoughtful reader in that it affords a faithful transcript of German
life in time gone by; the authors, although so circumscribed in
space, are in some sort historians of piquant social conditions. It is
commonly said that your true short-story writer is not a novelist, nor
the other way about. But The Dean's Watch, and a dozen other tales
that could be named, are little master-pieces not to be omitted in
any just, comprehensive survey of these fecund authors.
The National Novels differ from these simpler tales in more than
theme and the fuller body and greater variety they possess; the
authors' aim in the series sets the books apart from the other
stories. This group is made up of tales that fairly may be called
"purpose fiction," in the present cant. Erckmann-Chatrian agree to
hate war and to justify their hate by writing a succession of books
portraying its horrors, always from the disadvantage-point of actual
humble participants and onlookers, so that the plea shall appear to
be at once fairly made and yet be overwhelming in effect. Of the
result, surely it may be said of the National Novels that if they are
not magnificent, they are war—war stript of its glory, reduced to the
one grim denominator of human misery.
The successive national struggles of France towards that
peaceful Republicanism which has now endured long enough to
induce the outside world into a belief that this volatile, fiery people
will never revert to any form of monarchy, are sketched so
graphically as to give a clear comprehension of their history.
Nowhere is the artistry of the authors better exhibited than in the
skill with which, by placing their own position in the mouths of
others and by means of their remarkable power in characterization,
they rob special pleading of that didacticism which is so deadly an
enemy of good fiction. To secure an effect of verisimilitude no
method of story-telling is perhaps so useful as that in which one of
the characters speaks in proper person. What the author loses in
omniscience, he more than gains in the impression of reality. This
method is admirable in the hands of Erckmann-Chatrian, who
consistently use it in their fiction. Do the writers of any other nation,
one is tempted to query, offer such frequent examples of good taste
in this avoidance of the too didactic as do the French? In some
English hands so strenuous an attempt would have seemed heavily
intolerable. Here one forgets all but the naturalness of word and
action in the characters; and the lesson sinks the deeper into the
mind.
In justice both to our authors and the present-day temper, it
may be declared that the Twentieth Century is likely to be more
sympathetic to their particular thesis than was their own time. There
is a popular treatment of war which bedecks it in a sort of stage
tinsel, to the hiding of its gaunt figure and cadaverous face. Some of
Scott's romances are of this order. Zola, with his epic sweep in Le
Débâcle, does not disguise the horrors of the Franco-Prussian
struggle. Yet epic it is, and in a sense, romantic; handled by a poet
whose imagination is aroused by the magnitude and movement of
his theme. Erckmann-Chatrian set themselves squarely against this
conception; they reduce the splendid trappings and elan of battle to
its true hideousness.
In order to depict the inevitable, wretched results of the killing
of men for purposes of political ambition, or national
aggrandizement, Erckmann-Chatrian, as in their provincial idyls, cling
steadily to the position of the average man, who cannot for the life
of him see the use of leaving all that is pleasant and dear, of
fighting, marching, sickening, and dying for the sake of a cause he
does not understand or believe in, as the slave of men whom he
perhaps despises. Joseph Berta, the lame conscript, the shrewd,
kindly Jew Mathieu, the common-sense miller Christian Weber,
protagonists in three well-known stories, each distinct from the
other, are all alike in their preference for peace over war, for the joy
of home and the quiet prosecution of their respective affairs, instead
of the dubious pleasures of siege and campaign.
There is a superbly bourgeois flavour to it all. Yet one feels its
force, its sound humanity. The republicanism of these writers is of
the broadest kind. They hate Bonaparte or Bourbon, because in their
belief either house stands for tyranny and corruption; while
Napoleon is their special detestation, the later Empire is vigorously
assailed because it, too, is opposed to the interests of the people.
Napoleon III., whom in high satiric scorn they pillory as "The Honest
Man," comes in for savage condemnation, since he again brings woe
upon the working folk, in pursuit of his own selfish ends. And
underneath all, like a ground-swell can be felt a deep and genuine, if
homely, patriotism.
Human nature, as it is witnessed in the pages of Erckmann-
Chatrian, is not hard to decipher. It lacks the subtlety of the modern
psychologue, miscalled a novelist. Humanity for them is made up of
two great contrasted elements—the people and the enemies of the
people; the latter made up of kings, politicians, government leaders,
and the general world of bureaucracy, who fleece the former, "that
vast flock which they were always accustomed to shear, and which
they call the people." But the people themselves, how veritable and
charming they are! Not a whit are they idealized; the fictional folk of
these writers are always recognisable; they give us that pleasure of
recognition which Mr. James points out as one of the principal
virtues of modern novel-making. The title of one of the well-known
books, The History of a Man of the People, might almost stand as a
description of their complete works. There is no sentimentalizing of
average humanity; none of the Auerbach or George Sand
prettification of country life. Erckmann-Chatrian are as truthful as a
later realist like Thomas Hardy. The family life in The Brigadier
Frederick is almost lyrically set forth, until it seems, mayhap, too
good for human nature's daily food; but similar scenes in other
stories have a Dutch-like fidelity in their transcripts of the coarser,
less lovely human traits; recall the wife and daughter of Weber, for
example, or the well-nigh craven fear of Joseph Berta in The
Plebiscite, who seems half a poltroon until he is seasoned in a
Napoleonic campaign; the psychologic treatment here suggesting
Stephen Crane's The Red Badge of Courage. The blend of grim
realism and heroic patriotism in the figure of the old sergeant in The
Plebiscite is a fine illustration of that truth to both the shell and
kernel of life which Erckmann-Chatrian maintain throughout their
work.
On the whole, then, it is a comfortable, enheartening
conception of Man they present. Poor theologians they would make;
men are by nature good and kind; only warped by cruel misuse and
bad masters, as in war. "Ah, it is a great joy to love and to be loved,
the only one joy of life," exclaims the Jew Mathieu in The Blockade.
This simple yet sufficient creed pervades their thought. Again and
again is it declared that whatever the apparent evil, so that the
faithful-hearted and devout of the world, like Father Frederick, lose
courage for the moment, the fault is with men upon earth, not in
heaven. High over all, God reigns. A spirit of kindliness, quiet,
unheroic, but deep and tender, enswathes the more serious part of
these novels like an atmosphere; and if the mood shifts to
indignation, it is the righteous indignation of the good in the face of
that which is wrong and evil. And these better human attributes are
most commonly found in the provinces; the city, as a rule, spells sin.
The touch of mother earth brings purity and strength. "La mauvaise
race qui trompe," declares the Brigadier Frederick, "n'existe pas au
pays; elle est toujours venue d'ailleurs." One smiles at this, but it
offends not nor seems absurd. Its very prejudice is lovable.
Perhaps none of the stories make so moving an appeal against
war as The Brigadier Frederick. Its sadness is the most heartfelt, its
realism the most truthful, and hence effective. Nor in any other book
of the War Series does the French character shine more clearly in its
typical virtues. Family love and faith, camaraderie, humble
devoutness in religion, and earnest patriotism are constantly made
manifest in this fine tale. Instead of conducting their hero through
the spectacular scenes of military campaigns, the authors depict only
the stay-at-home aspects of war, which because of their lack of strut
and epic colour are, as a rule, overlooked, and which yet illustrate
far better than the most Zolaesque details the wretched milieu and
after effects of a great national struggle. Frederick, the old guard of
the Alsatian forest domains, loses in turn his post, his son-in-law,
wife, and daughter, and at last his native land; and through all his
misery remains proudly a Frenchman, who refuses to declare
allegiance to the German invaders; and, in being true to his
convictions, furnishes a noble example of a man who, by the moral
test, rises superior to any fate, his head being

"bloody but unbowed."

Again, sad as the story is, it differs from too much of the tragedy of
current literature; it is sad for the sake of a purpose, not for sadness'
sake. Alleviation is offered the reader from the beginning, in that he
knows that Frederick himself has survived all his woes, since he is
telling his tale to a friend in after years. These qualities make the
work wholesome and beautiful, sound both for art and life.
Erckmann-Chatrian draw strength from mother-soil. Their
stories are laid in Alsace-Lorraine, or at least it is that debatable land
whence the characters go only to return for the peaceful
denouement, which these authors, in the good old-fashioned style,
like to offer their readers. The popularity of such writers brings us
back, happily, to that untechnical valuation of literature which insists,
first of all, in regarding it as an exposition of human experience.
Their books bear translation especially well because there is
something in them besides incommunicable flavours of style, though
style is not wanting; namely, vital folk, vivid scenes, significant
happenings. Theirs is the misleading simplicity of method and
manner which hides technique of a rare and admirable kind.
Allowing for all exaggeration for altered ideals in fiction, and for the
waning of interest in the historical circumstances which they portray,
there remain such elements of permanent appeal as to give their
books far more than a transient worth.
For more than forty years, Erckmann-Chatrian wrote as one
man; their collaboration was, in effect, a chemical union. No
example in literature better illustrates the possibility of the merging
of individualities for the purposes of artistic unity. The double work
of the English Besant and Rice is by no means so important nor do
they stand and fall together in the same sense; much of Besant's
typical fiction being produced after his partner's death. In the case
of the most famed collaboration of older days, that of the dramatists
Beaumont and Fletcher, the union was more intimate. But the early
death of Beaumont, the consideration that he wrote less than half
the plays conventionally attributed to their joint authorship, and the
additional consideration that some of the best and most enjoyable
dramas associated with these great names—The Loyal Subject, to
mention but one—are unquestionably of Fletcher's sole composition,
make the Beaumont-Fletcher alliance not so perfect an example of
literary collaboration as is offered by Erckmann-Chatrian. When
Chatrian died in 1890, it was as if, for literary purposes, both died.
Their work had a unity testifying to a remarkable if not unique
congeniality in temperament, view and aim, as well as to a fraternal
unity which—alas! the irony of all human friendships—was dispelled
when their quarrel, just before the death of Chatrian, put an end to
an association so fruitful and famous.
From the very nature of fiction in contrast with drama, it would
seem as if collaboration in stage literature were more likely to yield
happy results than in the case of the novel. Here, however, is an
example setting aside a priori reasoning; seemingly "helpless each
without the other," the final breach in their personal relations would
seem to have written Finis to their literary endeavour. Yet Erckmann
survived for nearly a decade and wrote military stories, which in
tone and temper carried on the traditions of the two men. But we
may easily detect in this last effort the penalty of their literary
severance: the loss of the craftsmanship of Chatrian was a loss
indeed. Nor is this subjective guess-work of the critic; Erckmann
himself described nearly twenty years ago the respective parts
played by the two in their literary work. He declared that after a
story had been blocked out and thoroughly talked over between
them, he did all the actual composition. Then was it Chatrian's
business to point out faults, to suggest, here a change in
perspective, there less emphasis upon a subsidiary character, or here
again, a better handling of proportion—in short, to do all the
retouching that looks to artistry. And Erckmann goes on to testify in
good set terms how necessary his collaborator was to the final
perfected form of the story; how much it must have suffered without
his sense of technique. It would appear from this that the senior
member of the firm did what is commonly called the creative work of
composition, the junior filling the role of critic. From France one
hears that Erckmann was very German in taste and sympathy
(mirabile dictu! in view of so much of what he wrote); Chatrian,
French to the core, a man who insisted on residing on the French
side of the national line, who reared his sons to be French soldiers;
whereas Erckmann in later years hobnobbed with the Germans,
members of his family, in fact, inter-marrying with his ancient
enemies.
Indeed, this last act of their personal history has its
disillusionment. But after all, men shall be judged in their works.
Whatever their private quarrellings, their respective parts in literary
labour, their attributes or national leanings, the world, justly caring
most in the long run for the fiction they wrote, will continue to think
of them as provincial patriots, lovers of their country, and
Frenchmen of the French, not only in the tongue they used, but in
those deep-lying characteristics and qualities which make their
production worthily Gallic in the nobler implication of the word.

RICHARD BURTON.

BIOGRAPHICAL NOTE

The celebrated friends who collaborated for fifty years under the title
of ERCKMANN-CHATRIAN were natives of the department of the
Meurthe, in Alsace-Lorraine. ÉMILE ERCKMANN was born at
Phalsbourg (now Pfalzburg), on the 20th of May, 1822. His father
was a bookseller; his mother he lost early. He was educated at the
Welcome to Our Bookstore - The Ultimate Destination for Book Lovers
Are you passionate about books and eager to explore new worlds of
knowledge? At our website, we offer a vast collection of books that
cater to every interest and age group. From classic literature to
specialized publications, self-help books, and children’s stories, we
have it all! Each book is a gateway to new adventures, helping you
expand your knowledge and nourish your soul
Experience Convenient and Enjoyable Book Shopping Our website is more
than just an online bookstore—it’s a bridge connecting readers to the
timeless values of culture and wisdom. With a sleek and user-friendly
interface and a smart search system, you can find your favorite books
quickly and easily. Enjoy special promotions, fast home delivery, and
a seamless shopping experience that saves you time and enhances your
love for reading.
Let us accompany you on the journey of exploring knowledge and
personal growth!

ebookball.com