16.2 High-Weight Pathologies: Respiratory & Skeletal

16.2 High-Weight Pathologies: Respiratory & Skeletal

Quick Answer: CAMRT gives high secondary weight to respiratory and skeletal pathology. As an RTR you recognize patterns that affect image critique, technique, and urgent communication—pneumonia, pneumothorax, effusion, COPD/emphysema, atelectasis, pulmonary edema, foreign body, and major fracture/dislocation patterns—while not freestyle diagnosing beyond facility policy. Describe, protect the patient, add the right projection when needed, and alert the care team.

Chapter 7 introduced pathophysiology for procedure planning (additive vs destructive disease, mobility limits). This section is RTR.6 image-analysis application: what you see, what you do not miss, and when you stop the workflow to escalate.

How Recognition Differs from Diagnosis

Exam items reward the candidate who protects diagnostic quality and escalates the right emergencies.

Respiratory Pathologies (High Weight)

Pneumonia patterns

• Appearance cues: focal or multifocal opacity/consolidation; air bronchograms may be visible; silhouette sign when opacity contacts heart/diaphragm borders
• Critique links: under-inspiration and rotation create false basilar “disease”—do not accept a rotated poor-inspiration chest as “proven pneumonia”
• Technique: consolidative (additive) disease may need exposure judgment so mottle does not hide air bronchograms; follow AEC/manual protocols carefully
• Communication: new dense lobar-type opacity on a patient with fever/hypoxia is clinically important—ensure image reaches the interpreting/clinical team promptly

Pneumothorax

• Appearance cues: visceral pleural line with absence of lung markings peripheral to that line; large pneumothorax may show lung collapse toward the hilum
• Upright preferred when possible; expiration views sometimes requested to accentuate small PTX (follow order/protocol)
• Supine trauma: air rises anteriorly—may see deep sulcus sign rather than a classic apical line
• Tension pattern (urgent): mediastinal shift away from the lucent side, flattened diaphragm—immediate clinical alert; do not delay care for cosmetic repeats
• Mimics: skin folds, scapular edges, clothing—trace whether vessels cross the “line”

Pleural effusion

• Upright: blunted costophrenic angles; meniscus sign; larger effusions opacify lower hemithorax
• Supine: layering veil-like opacity; may underestimate volume
• Lateral decubitus (affected side down for free fluid layering—know local teaching; some protocols use opposite side for air—follow ordered intent) demonstrates free fluid mobility
• Critique: ensure true erect posture when “upright effusion” is the question; a semi-erect portable is not a true upright
• Additive fluid → attenuation up; watch exposure

COPD / emphysema

• Cues: hyperinflation (flattened diaphragms, increased retrosternal air on lateral), radiolucent lungs, narrowed vertical heart, bullae in some patients
• Technique: destructive/air-rich lungs—avoid unnecessary overexposure; still penetrate mediastinum adequately
• Positioning: patients may be dyspneic—coach short, effective inspiration; portable AP common in exacerbations
• Do not assume every hyperlucent lung is COPD—technique and PTX remain on the differential of “too black”

Atelectasis

• Cues: volume loss—fissure shift, mediastinal shift toward the opacity, elevated hemidiaphragm, crowded vessels/ribs
• Vs pneumonia: both can be opaque; volume-loss signs favour atelectasis patterns
• Post-op / mucus plug / malpositioned ET tube: if tube is too deep (often right mainstem), left lung volume loss may appear—check lines/tubes on every ICU chest
• Critique action: if ET tube tip appears at the carina or in a main bronchus, escalate immediately

Pulmonary edema (cardiogenic pattern awareness)

• Cues: vascular redistribution/cephalization (classic upright), perihilar haze, Kerley lines, bat-wing opacities, pleural effusions often bilateral
• Portable AP limits vascular redistribution signs—still note diffuse opacities and cardiomegaly appearance (AP magnifies heart)
• Additive process—mottle can hide interstitial lines if underexposed
• Urgent if flash edema with respiratory distress—process and communicate quickly

Foreign body (airway / chest)

• Children: aspirated FB may cause unilateral hyperlucency (air trapping) or atelectasis; history is critical
• Soft-tissue neck and dedicated airway protocols when ordered
• Iatrogenic: broken catheter fragments, misplaced lines—scan the entire FOV including corners
• Communication: suspected airway FB with distress is emergency pathway, not “wait for batch reading”

Lines and tubes (always part of “respiratory” critique)

Even when the order is “chest x-ray,” RTRs screen:

You are not the final interpreter, but obvious malposition is a stop-and-notify finding.

Skeletal Pathologies — Fractures (High Weight)

Language for recognition (not formal reporting)

Know the vocabulary so exam stems and trauma teams make sense:

High-yield named patterns

Dislocations

• Shoulder: anterior common (humeral head inferior/medial on AP; confirm with Y or axillary as safely possible)
• Posterior shoulder: often subtle on AP—Y / axillary critical; lightbulb appearance awareness
• Hip: emergent reduction pathway; two views; no frog-leg if unclear trauma
• Critique rule: if a single AP cannot exclude dislocation, add the ordered orthogonal/special view rather than repeating the same inadequate projection endlessly

Other Skeletal Conditions (High Secondary Weight)

Osteoarthritis (OA)

• Joint space narrowing, osteophytes, subchondral sclerosis (interpretive detail varies)
• RTR impact: limited ROM—use supports; weight-bearing extremities when ordered for true joint space; do not force positions that violate pain limits without clinical agreement

Osteoporosis

• Radiolucent bone, cortical thinning; higher fracture risk (vertebral, hip, wrist)
• Technique: destructive relative to dense bone—watch overpenetration and mottle balance
• Handling: log-roll carefully; fall precautions

Scoliosis

• Lateral curvature; series may include PA (or AP) full spine, lateral, flexion/bending per protocol
• Critique: consistent SID, no grid mismatch across stitched segments; markers and special annotations for side and projection; gonad shielding policies vary—never hide required anatomy

Dislocations vs subluxation awareness

Partial vs complete loss of joint congruence—orthogonal imaging is the technologist’s friend.

When to Alert Radiologist / ED (Without Over-Diagnosing)

Escalate promptly (examples):

• Tension pneumothorax pattern with shift
• ET/NGT in airway/lung or coiled unsafely
• Unstable-appearing pelvic or cervical findings in trauma context
• Suspected open fracture with contamination risk messaging to clinical team
• Foreign body in airway with distress
• Unexpected free air under diaphragm on chest/abdomen if clinically relevant pathway exists

Do not:

• Delay emergency clinical care to perfect windowing
• Publicly announce definitive cancer diagnoses from a portable chest
• Refuse to image a needed orthogonal view “because it looks broken enough already” when the order/protocol still requires it and the patient can be safely positioned

Linking Pathology to Image Acceptance

Ask three questions on every high-weight study:

1. Is the clinical question answerable on this projection set? (e.g., PTX needs adequate lung apex/periphery; Colles needs true lateral)
2. Did technique or positioning create a mimic?
3. Is there an urgent finding that changes immediate patient management?

If (1) fails → add/repeat projections (16.4). If (3) is yes → communicate now.