Find radiological images and try to include MRI, CT, and X-ray images for a particular limb, let's take upper limb right now, and discuss different diseases and which modality to use, when and why.

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Upper Limb Radiology: Modalities, Diseases, and When to Use Each

Source: Grainger & Allison's Diagnostic Radiology (9780323760751); Imaging Anatomy: Bones, Joints, Vessels and Nerves (9781626239845)

The Three Modalities - Quick Summary

Modality	Best For	Limitations
X-ray (Plain Radiograph)	Bones, fractures, alignment, arthritis, calcification	No soft tissue detail; misses early or occult fractures
CT	Complex fracture geometry, bony detail, surgical planning, articular cartilage (with contrast)	Radiation; poor soft-tissue contrast without arthrography
MRI	Tendons, ligaments, cartilage, labrum, bone marrow oedema, nerve compression	Slow, expensive, limited in acute trauma triage

REGION 1 - THE SHOULDER

Anatomy Context

The glenohumeral joint (GHJ) is the most mobile joint in the body - a "golf ball on a tee" configuration, making it inherently unstable. Stability comes from the rotator cuff (subscapularis, supraspinatus, infraspinatus, teres minor), the glenoid labrum, and glenohumeral ligaments. The subacromial space between the humeral head and acromion is where most impingement occurs.

Disease 1 - Rotator Cuff Impingement and Subacromial Enthesophyte

Modality of choice: X-ray first, then MRI

X-ray is the starting point. An AP shoulder radiograph shows bony enthesophyte (bone spur) formation on the lateral acromion or greater tuberosity, which narrows the subacromial space and drives the impingement process. Subacromial space narrowing below 7 mm on AP view is a specific (though insensitive) sign of significant rotator cuff disease.

Fig. 39.1 - AP X-ray of shoulder showing subacromial enthesophyte on the lateral acromion and greater tuberosity, secondary to external impingement

Why X-ray here: Cheap, fast, shows bony architecture, acromial shape, AC joint osteophytes, and helps exclude GHJ arthritis. Cannot show the tendon itself.

Disease 2 - Rotator Cuff Arthropathy (Chronic Full-Thickness Tear)

Modality of choice: X-ray for diagnosis, MRI for surgical planning

When a full-thickness rotator cuff tear becomes long-standing, the humeral head migrates superiorly to abut directly against the undersurface of the acromion. This is visible on a plain AP radiograph as marked subacromial space narrowing with femoralization of the humeral head.

Fig. 39.2 - AP X-ray showing rotator cuff arthropathy: superior migration of the humeral head with direct bony impingement against the acromion due to chronic full-thickness cuff tear

Why X-ray here: Sufficient to make the diagnosis when the space is clearly obliterated. MRI is then used to characterize residual cuff muscle quality (fatty infiltration, atrophy), which determines whether a reverse shoulder arthroplasty is feasible.

Disease 3 - Full-Thickness Supraspinatus Tear

Modality of choice: MRI

MRI directly visualizes the tendon substance. The primary sign is a focal defect through the full tendon thickness filled with fluid (high signal on T2/FS sequences). Secondary signs include fluid in both the GHJ AND the subacromial bursa simultaneously - pathognomonic of a full-thickness communication between the two compartments.

Fig. 39.4 - Coronal oblique T2 fat-saturated MRI: full-thickness supraspinatus tear filled with high-signal fluid (white arrow). Fluid is also present around the biceps tendon sheath (black arrow) and within the subacromial bursa (curved white arrow), confirming abnormal communication

Why MRI here: Nearly 100% accuracy for full-thickness tears. Critical pre-operative information includes tear size and shape (crescentic, U-shaped, or L-shaped), tendon retraction distance, degree of supraspinatus muscle atrophy, and whether infraspinatus or subscapularis are also involved. CT adds nothing for soft tissue here.

Disease 4 - SLAP Tear (Superior Labrum Anterior to Posterior)

Modality of choice: MRI Arthrography

Standard MRI may miss subtle labral tears. MR arthrography (intra-articular gadolinium) distends the joint, driving contrast into any labral cleft. A SLAP tear appears as high-signal contrast medium extending into the substance of the superior labrum.

Fig. 39.14 - Coronal FS T2 MR arthrogram: high-signal contrast medium extending into the superior labrum (arrow), confirming a SLAP tear

Why MR arthrography: Plain MRI is less sensitive for partial labral tears. Gadolinium arthrography is the gold standard for instability lesions. It shows Bankart lesions (anterior-inferior labral tears), Hill-Sachs deformities, and SLAP tears simultaneously.

Disease 5 - AC Joint Disruption

Modality of choice: X-ray first, MRI for soft tissue assessment

The acromioclavicular joint (ACJ) is assessed on AP views. Widening, superior displacement of the clavicle, and disruption of the coracoclavicular distance indicate grade of injury. MRI can show partial capsular stripping and haemorrhage when X-ray appears near-normal.

Fig. 39.15 - Sagittal T1 MRI (A) showing normal coracoclavicular ligament. FS T2 (B) in traumatic ACJ disruption: fluid in the joint, capsular stripping (arrowhead), and surrounding soft-tissue haemorrhage. C = clavicle, A = acromion, Co = coracoid, H = humerus

REGION 2 - THE ELBOW

The elbow is a complex hinge joint comprising the ulnotrochlear and radiocapitellar articulations (flexion/extension) and the proximal radioulnar joint (pronation/supination). The UCL (medial) and radial collateral complex stabilize the joint.

Disease 6 - Lateral Epicondylitis (Tennis Elbow) and Medial Epicondylitis (Golfer's Elbow)

Modality of choice: Ultrasound (first line); MRI for refractory cases

Insertional tendinopathy of the common extensor origin (lateral) or common flexor origin (medial) is the most common tendon pathology around the elbow. MRI shows tendon thickening, increased T2 signal (oedema), and partial tears at the epicondyle. For refractory cases, ultrasound-guided injection or needle therapy can be performed under real-time guidance - a therapeutic advantage that MRI cannot offer.

Why MRI over CT here: CT cannot visualize tendon substance. MRI shows the extent of tendinopathy, associated intrasubstance tearing, and whether bone marrow oedema of the epicondyle is present.

Disease 7 - Osteochondritis Dissecans (OCD) of the Capitellum

Modality of choice: MRI or CT Arthrography for fragment stability

The capitellum is the third most common site for OCD (after the medial femoral condyle and talus). The key clinical question is whether the fragment is stable (intact articular cartilage) or unstable (loose body risk). MRI shows low T1 signal in the subchondral bone. Crucially, high-signal fluid or contrast medium extending around the base of the lesion indicates instability.

CT arthrography offers excellent spatial resolution for articular cartilage integrity and is a useful alternative when MRI is unavailable or in patients with metallic implants.

Fig. 39.23/24 - CT of the elbow: (A) Axial CT showing early osteoarthritis with an olecranon osteophyte. (B) Sagittal CT arthrogram demonstrating a non-radiopaque chondral loose body in the posterior recess (white arrow)

Why CT arthrography here: When evaluating OCD stability or post-traumatic chondral loose bodies, CT arthrography provides exquisite bony detail with simultaneous cartilage assessment. Axial CT slices also show olecranon osteophytes and intra-articular bodies that plain X-ray may miss because they are radiolucent.

Disease 8 - Radial Head Fracture / Elbow Fractures

Modality of choice: X-ray first; CT for complex or occult fractures

Plain radiographs (AP and lateral) are the first step. A posterior fat pad sign on the lateral view indicates joint effusion and should raise suspicion of an occult fracture (most often radial head in adults; supracondylar in children). When X-rays are equivocal but clinically fracture is suspected, CT provides multiplanar reconstruction to identify fracture lines, fragment displacement, and articular step-off critical for surgical planning.

Why CT over MRI for fractures: CT is faster, widely available in emergency settings, and gives precise bony anatomy. MRI adds bone marrow oedema (useful for occult fractures) but is slower and impractical acutely. CT is preferred when surgical planning is needed.

REGION 3 - WRIST AND HAND

The wrist mechanics depend on the intercalated segment (scaphoid-lunate-triquetrum). The triangular fibrocartilage complex (TFCC) stabilizes the distal radioulnar joint. The carpal tunnel contains the median nerve and all flexor tendons.

Disease 9 - TFCC (Triangular Fibrocartilage Complex) Tear

Modality of choice: MRI Arthrography

The TFC disc arises from the ulnar border of the distal radius and attaches to the fovea and ulnar styloid. Central perforations are degenerative and common with age. Peripheral tears at the ulnar styloid attachment are traumatic and surgically repairable. On coronal T2-weighted gradient-echo MRI or MR arthrography, contrast medium or fluid extending through the TFC defect is diagnostic.

Fig. 39.34 - MR arthrogram of the wrist showing a large central TFC defect (curved white arrow) outlined by high-signal intra-articular contrast, with associated osteoarthritic changes and a subchondral cyst in the distal ulna

Why MRI here: The TFC is a fibrocartilaginous structure invisible on X-ray. CT can show arthritic changes but cannot characterize the TFC. MR arthrography is the gold standard, distinguishing central (degenerative) from peripheral (traumatic) tears which have different surgical implications.

Disease 10 - Scaphoid Fracture

Modality of choice: X-ray first; MRI or CT for occult fractures

Scaphoid fractures are the most common carpal fracture (80% of all carpal fractures), typically from a fall on an outstretched hand. The scaphoid waist is the most common site. Up to 20% of scaphoid fractures are occult on initial X-ray.

X-ray: PA, lateral, and scaphoid views. Positive in most displaced fractures.
CT: Used when surgical planning is needed to assess fracture displacement, comminution, and alignment for percutaneous screw fixation.
MRI: Gold standard for occult fractures - T1-weighted images show a dark fracture line; STIR/fat-suppressed T2 shows adjacent bone marrow oedema within 24 hours. MRI also shows avascular necrosis of the proximal pole (dark T1, dark T2 in the proximal fragment).

Why MRI for occult scaphoid: An untreated scaphoid fracture carries a 30% non-union rate and risk of avascular necrosis. MRI avoids unnecessary immobilization when truly negative and confirms the diagnosis when X-ray is misleading.

Disease 11 - De Quervain's Tenosynovitis

Modality of choice: Ultrasound (first line); MRI for confirmation

Stenosing tenosynovitis of the first extensor compartment (abductor pollicis longus and extensor pollicis brevis) produces radial-sided wrist pain. Ultrasound shows tendon thickening, fluid in the tendon sheath, and increased vascularity. MRI confirms the diagnosis when ultrasound is equivocal.

Why ultrasound over MRI here: Real-time dynamic assessment during thumb movement is possible with ultrasound. It also guides corticosteroid injection directly into the first compartment - a combined diagnostic and therapeutic approach.

Disease 12 - Rheumatoid Arthritis of the Hand and Wrist

Modality of choice: X-ray for monitoring; MRI for early disease

X-ray: Classic findings include periarticular osteopenia, joint space narrowing, marginal erosions at the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints, ulnar deviation of the fingers, and volar subluxation. AP views of both hands are standard for monitoring.
MRI: Far more sensitive in early RA. Synovitis, tenosynovitis, and bone marrow oedema (osteitis) precede erosions by months to years. Early MRI findings predict subsequent erosive damage. Contrast-enhanced MRI shows synovial enhancement.

Why MRI for early RA: Bone erosions on X-ray reflect established disease. MRI detects subclinical synovitis and bone marrow oedema before irreversible joint damage, enabling earlier treatment escalation (DMARD therapy).

Disease 13 - Carpal Tunnel Syndrome

Modality of choice: Ultrasound (first line); MRI when structural cause is suspected

CTS is a neuropathy of the median nerve, usually idiopathic but can follow wrist fractures, rheumatoid tenosynovitis, or ganglion cysts within the tunnel. Diagnosis is primarily clinical + nerve conduction studies.

Ultrasound: Shows median nerve cross-sectional area (>10-12 mm² is abnormal) and flattening at the pisiform level. Can detect ganglion cysts, accessory muscles, or other structural causes.
MRI: Shows nerve signal change (T2 hyperintensity), swelling of the median nerve proximal to the flexor retinaculum, and identifies mass lesions (lipomas, ganglia, peripheral nerve sheath tumours) responsible for compression.

Summary: When to Use Each Modality

Clinical Scenario	First Line	Second Line	Avoid / Less Useful
Acute trauma (fracture suspected)	X-ray	CT (complex fractures)	MRI (unless occult fx)
Occult scaphoid fracture	X-ray	MRI (gold standard)	CT misses marrow oedema
Rotator cuff tear	X-ray (exclude arthritis)	MRI	CT
Labral tears (SLAP, Bankart)	-	MRI arthrography	Plain MRI less sensitive
Tendinopathy (tennis/golfer's elbow)	Ultrasound	MRI	CT
OCD capitellum - stability	MRI	CT arthrography	Plain X-ray (late only)
TFCC tear	-	MRI arthrography	CT
Elbow OA / loose bodies	X-ray	CT arthrography	MRI (less spatial res.)
RA hand monitoring	X-ray (serial)	MRI (early disease)	CT
Carpal tunnel syndrome	Ultrasound	MRI (mass lesion)	CT
Complex periarticular fracture	X-ray	CT	MRI acutely
Bone tumour / AVN	X-ray	MRI	CT (supplementary)

Key Principles

X-ray is always the entry point for musculoskeletal imaging. It is fast, inexpensive, gives a structural overview, and is mandatory before any further imaging. Never proceed to CT or MRI without prior radiographs.

CT excels at bone detail - fracture geometry, comminution, articular surface displacement, and pre-surgical planning. CT arthrography adds cartilage assessment and is a strong alternative to MR arthrography in patients with metallic implants (prostheses, pacemakers) or claustrophobia.

MRI is the workhorse for soft-tissue pathology. The rotator cuff, labrum, intrinsic ligaments of the wrist, tendons, nerves, and bone marrow are all best seen on MRI. Fat suppression sequences (STIR, FS-T2) highlight oedema and fluid. Arthrography (intra-articular gadolinium) improves sensitivity for partial tears of the labrum and ligaments.

Ultrasound (though not the focus here) should not be forgotten for tendons and guided procedures - it offers real-time dynamic assessment, is operator-dependent but highly sensitive for superficial structures.

Sources: Grainger & Allison's Diagnostic Radiology (Elsevier, 2021), Chapter 39 - Musculoskeletal System (Upper Limb); Imaging Anatomy: Bones, Joints, Vessels and Nerves, Vol. 3 (Thieme, 2015)

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  s.addText("Plain Radiograph of the Shoulder", {
    x: 0.35, y: 1.28, w: 3.6, h: 0.32,
    fontSize: 12, fontFace: "Palatino Linotype", italic: true,
    color: C.sage, margin: 0
  });

  // Gold divider
  s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y: 1.7, w: 3.4, h: 0.025, fill: { color: C.gold }, line: { color: C.gold } });

  // Bullet points
  const bullets = [
    ["Bony enthesophytes", "Acromion / greater tuberosity spurs on AP view drive impingement."],
    ["Subacromial space", "Narrowing <7 mm = specific sign of full-thickness cuff tear."],
    ["Rotator cuff arthropathy", "Superior humeral migration → femorisation of humeral head."],
    ["When to use", "Always first-line. Fast, inexpensive, excellent bony overview."]
  ];
  bullets.forEach(([title, body], i) => {
    s.addText(title, {
      x: 0.35, y: 1.85 + i * 0.82, w: 3.6, h: 0.3,
      fontSize: 11, fontFace: "Calibri", bold: true,
      color: C.gold, margin: 0
    });
    s.addText(body, {
      x: 0.35, y: 2.12 + i * 0.82, w: 3.6, h: 0.45,
      fontSize: 10, fontFace: "Calibri",
      color: "B0BFCA", margin: 0
    });
  });

  // Images — two X-rays side by side
  s.addImage({ data: img(0), x: 4.38, y: 0.25, w: 2.62, h: 2.56 });
  s.addImage({ data: img(1), x: 7.12, y: 0.25, w: 2.62, h: 2.56 });

  // Captions
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  s.addText("Fig. 39.1 — Subacromial enthesophyte on the lateral acromion (AP view)", {
    x: 4.45, y: 2.84, w: 2.48, h: 0.5,
    fontSize: 8, fontFace: "Calibri", italic: true, color: "6A6560", margin: 0
  });
  s.addShape(pres.shapes.RECTANGLE, { x: 7.12, y: 2.82, w: 2.62, h: 0.55, fill: { color: "EDEDEA" }, line: { color: C.divider } });
  s.addText("Fig. 39.2 — Rotator cuff arthropathy: superior humeral migration (AP view)", {
    x: 7.19, y: 2.84, w: 2.48, h: 0.5,
    fontSize: 8, fontFace: "Calibri", italic: true, color: "6A6560", margin: 0
  });

  // Bottom summary box
  s.addShape(pres.shapes.RECTANGLE, { x: 4.38, y: 3.52, w: 5.38, h: 1.85, fill: { color: "F0EBE2" }, line: { color: C.divider, pt: 0.5 } });
  s.addShape(pres.shapes.RECTANGLE, { x: 4.38, y: 3.52, w: 0.05, h: 1.85, fill: { color: C.teal }, line: { color: C.teal } });
  s.addText("Clinical Context", {
    x: 4.55, y: 3.6, w: 5.0, h: 0.3,
    fontSize: 11, fontFace: "Georgia", bold: true, color: C.teal, margin: 0
  });
  s.addText(
    "Impingement is the most common cause of rotator cuff tears in patients over 40. X-ray is mandatory before any further imaging. It reveals acromial shape, AC joint spurs, and calcific deposits within tendons (calcific tendinopathy). Marked subacromial narrowing with humeral head contact against the acromion is pathognomonic of chronic rotator cuff arthropathy.",
    {
      x: 4.55, y: 3.94, w: 5.0, h: 1.3,
      fontSize: 9.5, fontFace: "Calibri", color: C.text, margin: 0
    }
  );
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 4 — Shoulder: MRI (Rotator Cuff Tear + SLAP)
// ═══════════════════════════════════════════════════════════════════════════
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  // Header stripe
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  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0.82, w: 10, h: 0.04, fill: { color: C.teal }, line: { color: C.teal } });
  s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y: 0.15, w: 1.05, h: 0.28, fill: { color: C.teal }, line: { color: C.teal } });
  s.addText("SHOULDER", {
    x: 0.35, y: 0.15, w: 1.05, h: 0.28,
    fontSize: 8, fontFace: "Calibri", bold: true, color: C.white, align: "center", charSpacing: 2, margin: 0
  });
  s.addText("MRI  —  Magnetic Resonance Imaging", {
    x: 1.55, y: 0.18, w: 7, h: 0.5,
    fontSize: 22, fontFace: "Georgia", bold: true, color: C.white, margin: 0
  });

  // Two image columns
  // Left: Full-thickness tear
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    shadow: { type: "outer", color: "000000", blur: 6, offset: 2, angle: 135, opacity: 0.08 }
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  s.addText("Full-Thickness Supraspinatus Tear", {
    x: 0.4, y: 1.08, w: 4.2, h: 0.32,
    fontSize: 12, fontFace: "Georgia", bold: true, color: C.teal, margin: 0
  });
  s.addImage({ data: img(2), x: 0.4, y: 1.44, w: 4.18, h: 2.4 });
  s.addText(
    "Coronal oblique T2 fat-sat MRI. High-signal fluid fills the supraspinatus defect (white arrow). Fluid in both the GHJ and subacromial bursa confirms full-thickness communication — pathognomonic of a complete tear.",
    {
      x: 0.4, y: 3.88, w: 4.18, h: 1.05,
      fontSize: 8.5, fontFace: "Calibri", color: C.text, margin: 0
    }
  );

  // Right: SLAP tear
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    shadow: { type: "outer", color: "000000", blur: 6, offset: 2, angle: 135, opacity: 0.08 }
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  s.addText("SLAP Tear  —  MR Arthrography", {
    x: 5.2, y: 1.08, w: 4.4, h: 0.32,
    fontSize: 12, fontFace: "Georgia", bold: true, color: C.teal, margin: 0
  });
  s.addImage({ data: img(3), x: 5.2, y: 1.44, w: 4.38, h: 2.4 });
  s.addText(
    "Coronal FS T2 MR arthrogram. High-signal gadolinium contrast extends into the superior labrum (arrow) confirming a SLAP tear. MR arthrography is the gold standard — it distends the joint, driving contrast into subtle labral clefts that plain MRI misses.",
    {
      x: 5.2, y: 3.88, w: 4.38, h: 1.05,
      fontSize: 8.5, fontFace: "Calibri", color: C.text, margin: 0
    }
  );
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 5 — Shoulder: MRI AC Joint + Modality Decision
// ═══════════════════════════════════════════════════════════════════════════
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  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.dark }, line: { color: C.dark } });

  // Right side lighter panel
  s.addShape(pres.shapes.RECTANGLE, { x: 5.2, y: 0, w: 4.8, h: 5.625, fill: { color: "182430" }, line: { color: "182430" } });
  s.addShape(pres.shapes.RECTANGLE, { x: 5.2, y: 0, w: 0.04, h: 5.625, fill: { color: C.gold }, line: { color: C.gold } });

  s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y: 0.3, w: 1.05, h: 0.28, fill: { color: C.teal }, line: { color: C.teal } });
  s.addText("SHOULDER", {
    x: 0.35, y: 0.3, w: 1.05, h: 0.28,
    fontSize: 8, fontFace: "Calibri", bold: true, color: C.white, align: "center", charSpacing: 2, margin: 0
  });
  s.addText("AC Joint Disruption", {
    x: 0.35, y: 0.72, w: 4.5, h: 0.55,
    fontSize: 26, fontFace: "Georgia", color: C.white, margin: 0
  });
  s.addText("MRI for Soft-Tissue Assessment", {
    x: 0.35, y: 1.28, w: 4.5, h: 0.3,
    fontSize: 12, fontFace: "Palatino Linotype", italic: true, color: C.sage, margin: 0
  });

  s.addImage({ data: img(5), x: 0.3, y: 1.72, w: 4.7, h: 3.5 });

  // Right: Shoulder modality decision chart
  s.addText("Shoulder Imaging", {
    x: 5.4, y: 0.3, w: 4.2, h: 0.52,
    fontSize: 22, fontFace: "Georgia", bold: true, color: C.white, margin: 0
  });
  s.addText("Modality Selection Guide", {
    x: 5.4, y: 0.82, w: 4.2, h: 0.28,
    fontSize: 11, fontFace: "Palatino Linotype", italic: true, color: C.sage, margin: 0
  });
  s.addShape(pres.shapes.RECTANGLE, { x: 5.4, y: 1.18, w: 4.2, h: 0.025, fill: { color: C.gold }, line: { color: C.gold } });

  const decisions = [
    ["X-Ray",  "First-line for ALL shoulder presentations — bony architecture, impingement, arthritis"],
    ["MRI",    "Rotator cuff disease — tendon tears, bursitis, tendinopathy with near 100% accuracy"],
    ["MR Arthrography", "Instability lesions — SLAP, Bankart, labral tears (superior sensitivity)"],
    ["CT",     "Complex fractures (e.g. glenoid rim, humeral head), pre-surgical planning"],
    ["CT Arthrography", "Metallic implants present; alternative to MR arthrography"],
  ];
  decisions.forEach(([mod, desc], i) => {
    const y = 1.32 + i * 0.82;
    s.addShape(pres.shapes.RECTANGLE, { x: 5.4, y, w: 4.2, h: 0.72,
      fill: { color: i % 2 === 0 ? "1E3348" : "192B3B" }, line: { color: "2A3F52", pt: 0.4 }
    });
    s.addShape(pres.shapes.RECTANGLE, { x: 5.4, y, w: 0.04, h: 0.72, fill: { color: C.teal }, line: { color: C.teal } });
    s.addText(mod, {
      x: 5.52, y: y + 0.06, w: 4.0, h: 0.26,
      fontSize: 11, fontFace: "Calibri", bold: true, color: C.gold, margin: 0
    });
    s.addText(desc, {
      x: 5.52, y: y + 0.33, w: 4.0, h: 0.34,
      fontSize: 9.5, fontFace: "Calibri", color: "9AABB8", margin: 0
    });
  });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 6 — Elbow: CT (OA + OCD)
// ═══════════════════════════════════════════════════════════════════════════
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  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.parch }, line: { color: C.parch } });

  // Header
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.82, fill: { color: C.dark }, line: { color: C.dark } });
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0.82, w: 10, h: 0.04, fill: { color: C.gold }, line: { color: C.gold } });

  s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y: 0.15, w: 0.85, h: 0.28, fill: { color: C.gold }, line: { color: C.gold } });
  s.addText("ELBOW", {
    x: 0.35, y: 0.15, w: 0.85, h: 0.28,
    fontSize: 8, fontFace: "Calibri", bold: true, color: C.dark, align: "center", charSpacing: 2, margin: 0
  });
  s.addText("CT  —  Computed Tomography of the Elbow", {
    x: 1.32, y: 0.18, w: 8, h: 0.5,
    fontSize: 22, fontFace: "Georgia", bold: true, color: C.white, margin: 0
  });

  // Main CT image (large)
  s.addShape(pres.shapes.RECTANGLE, { x: 0.25, y: 1.0, w: 5.6, h: 4.35, fill: { color: "111111" }, line: { color: "333333", pt: 0.5 } });
  s.addImage({ data: img(4), x: 0.3, y: 1.08, w: 5.5, h: 3.2 });
  s.addText("Fig. 39.24 — CT Elbow: OA and CT Arthrography", {
    x: 0.35, y: 4.3, w: 5.5, h: 0.25,
    fontSize: 9, fontFace: "Georgia", italic: true, bold: true, color: C.gold, margin: 0
  });
  s.addText(
    "(A) Axial CT: olecranon osteophyte in early osteoarthritis.  (B) Sagittal CT arthrogram: non-radiopaque chondral loose body in the posterior recess (white arrow).",
    {
      x: 0.35, y: 4.56, w: 5.5, h: 0.62,
      fontSize: 9, fontFace: "Calibri", color: "606060", margin: 0
    }
  );

  // Right: key points
  const ctPoints = [
    ["Fractures",       "Multiplanar CT reconstructions for radial head fractures, supracondylar, and complex elbow injuries. Defines articular step-off for surgical planning."],
    ["OCD of Capitellum", "CT arthrography assesses osteochondral fragment stability. High spatial resolution confirms cartilage integrity — critical for operative decision."],
    ["Osteoarthritis",  "Loose body detection: radiolucent chondral bodies invisible on X-ray are revealed by intra-articular contrast on CT arthrography."],
    ["Why CT over MRI?", "Faster in acute settings, superior bony resolution, excellent for metallic implants, and enables guided arthrography simultaneously."]
  ];
  ctPoints.forEach(([title, body], i) => {
    const y = 1.05 + i * 1.12;
    s.addShape(pres.shapes.RECTANGLE, { x: 6.1, y, w: 3.65, h: 1.0,
      fill: { color: i % 2 === 0 ? "FFFFFF" : "F0EBE2" }, line: { color: C.divider, pt: 0.5 }
    });
    s.addShape(pres.shapes.RECTANGLE, { x: 6.1, y, w: 0.04, h: 1.0, fill: { color: C.gold }, line: { color: C.gold } });
    s.addText(title, {
      x: 6.22, y: y + 0.07, w: 3.4, h: 0.28,
      fontSize: 11, fontFace: "Calibri", bold: true, color: C.teal, margin: 0
    });
    s.addText(body, {
      x: 6.22, y: y + 0.35, w: 3.4, h: 0.6,
      fontSize: 9, fontFace: "Calibri", color: C.text, margin: 0
    });
  });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 7 — Wrist: MRI (TFCC tear)
// ═══════════════════════════════════════════════════════════════════════════
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  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.dark }, line: { color: C.dark } });
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 0.06, h: 5.625, fill: { color: C.sage }, line: { color: C.sage } });

  // Right image half
  s.addImage({ data: img(6), x: 4.8, y: 0.1, w: 5.0, h: 5.4 });
  // Overlay gradient-feel using semi-transparent rect
  s.addShape(pres.shapes.RECTANGLE, { x: 4.8, y: 0, w: 0.6, h: 5.625, fill: { color: C.dark }, line: { color: C.dark } });

  // Left content
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  s.addText("WRIST", {
    x: 0.35, y: 0.35, w: 1.1, h: 0.28,
    fontSize: 8, fontFace: "Calibri", bold: true, color: C.white, align: "center", charSpacing: 2, margin: 0
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  s.addText("MRI", {
    x: 0.35, y: 0.78, w: 4.2, h: 0.65,
    fontSize: 42, fontFace: "Georgia", bold: false, color: C.white, margin: 0
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  s.addText("Triangular Fibrocartilage\nComplex (TFCC) Tear", {
    x: 0.35, y: 1.46, w: 4.2, h: 0.7,
    fontSize: 16, fontFace: "Palatino Linotype", italic: true, color: C.sage, margin: 0
  });

  s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y: 2.25, w: 3.8, h: 0.025, fill: { color: C.gold }, line: { color: C.gold } });

  const wristPoints = [
    ["TFC anatomy", "Cartilaginous disc between distal radius, ulna and carpal bones. Stabilises the DRUJ."],
    ["Central (degenerative)", "Age-related perforation. MR arthrography shows contrast filling the defect. Usually not repaired."],
    ["Peripheral (traumatic)", "Ulnar styloid avulsion. Surgically repairable. Requires MR arthrography to distinguish."],
    ["Why MRI?", "The TFC is invisible on X-ray. CT cannot characterize fibrocartilage. MRI / MR arthrography is the gold standard."],
  ];
  wristPoints.forEach(([title, body], i) => {
    s.addText(title, {
      x: 0.35, y: 2.4 + i * 0.77, w: 4.0, h: 0.28,
      fontSize: 11, fontFace: "Calibri", bold: true, color: C.gold, margin: 0
    });
    s.addText(body, {
      x: 0.35, y: 2.66 + i * 0.77, w: 4.0, h: 0.42,
      fontSize: 9.5, fontFace: "Calibri", color: "9AABB8", margin: 0
    });
  });

  // Caption over image
  s.addShape(pres.shapes.RECTANGLE, { x: 5.45, y: 4.88, w: 4.35, h: 0.62, fill: { color: "0D1B27" }, line: { color: "0D1B27" } });
  s.addText("Fig. 39.34 — Coronal MR arthrogram wrist: central TFC defect (curved arrow) with high-signal contrast, associated OA changes and subchondral cyst in distal ulna.", {
    x: 5.52, y: 4.92, w: 4.22, h: 0.56,
    fontSize: 8, fontFace: "Calibri", italic: true, color: "8A9BAA", margin: 0
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}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 8 — Disease Summary Grid (all regions)
// ═══════════════════════════════════════════════════════════════════════════
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  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.parch }, line: { color: C.parch } });

  // Header
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.72, fill: { color: C.dark }, line: { color: C.dark } });
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0.72, w: 10, h: 0.04, fill: { color: C.teal }, line: { color: C.teal } });
  s.addText("DISEASE — MODALITY REFERENCE", {
    x: 0.35, y: 0.1, w: 9, h: 0.55,
    fontSize: 20, fontFace: "Georgia", bold: true, charSpacing: 2, color: C.white, margin: 0
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  const rows = [
    // region, disease, first, second, note
    ["Shoulder", "Rotator Cuff Impingement", "X-Ray", "MRI", "Bony spurs, acromial shape"],
    ["Shoulder", "Full-Thickness Cuff Tear", "MRI", "X-Ray (screen)", "~100% accuracy on MRI"],
    ["Shoulder", "SLAP / Bankart Labral Tear", "MR Arthrography", "—", "Gold standard for labrum"],
    ["Shoulder", "AC Joint Injury", "X-Ray", "MRI", "MRI for soft-tissue grading"],
    ["Shoulder", "Complex # / Glenoid Rim", "X-Ray", "CT", "CT for surgical planning"],
    ["Elbow", "Radial Head / Elbow Fracture", "X-Ray", "CT", "CT for articular step-off"],
    ["Elbow", "OCD Capitellum", "MRI", "CT Arthrography", "Stability of fragment"],
    ["Elbow", "Tennis / Golfer's Elbow", "Ultrasound", "MRI", "US allows guided injection"],
    ["Elbow", "Loose Bodies / OA", "X-Ray", "CT Arthrography", "Radiolucent bodies visible"],
    ["Wrist", "Scaphoid Fracture (occult)", "X-Ray", "MRI", "MRI detects marrow oedema"],
    ["Wrist", "TFCC Tear", "MR Arthrography", "—", "Central vs peripheral tear"],
    ["Wrist", "Carpal Tunnel Syndrome", "Ultrasound", "MRI", "MRI if mass lesion suspected"],
    ["Wrist", "Rheumatoid Arthritis", "X-Ray (serial)", "MRI", "MRI for early synovitis"],
  ];

  // Column headers
  const colX = [0.2, 2.1, 4.0, 5.6, 7.2];
  const colW = [1.85, 1.85, 1.55, 1.55, 2.7];
  const headers = ["Region", "Disease", "1st Line", "2nd Line", "Key Note"];
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      x: colX[i], y: 0.87, w: colW[i], h: 0.28,
      fontSize: 9, fontFace: "Calibri", bold: true, color: C.white, margin: 0, charSpacing: 1
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  });

  // Rows
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  rows.forEach((row, i) => {
    const y = 1.22 + i * 0.335;
    const bg = i % 2 === 0 ? "FFFFFF" : "F5F0E8";
    s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y, w: 9.6, h: 0.32, fill: { color: bg }, line: { color: "E0D8CF", pt: 0.3 } });
    row.forEach((cell, j) => {
      let opts = {
        x: colX[j], y: y + 0.03, w: colW[j], h: 0.26,
        fontSize: j === 0 ? 8.5 : 9, fontFace: "Calibri",
        color: j === 0 ? regionColors[cell] || C.text : j === 2 ? C.teal : C.text,
        bold: j === 0 || j === 2, margin: 0, valign: "middle"
      };
      s.addText(cell, opts);
    });
  });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 9 — Key Principles (closing)
// ═══════════════════════════════════════════════════════════════════════════
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  s.addText("KEY PRINCIPLES", {
    x: 0.5, y: 0.28, w: 9, h: 0.55,
    fontSize: 28, fontFace: "Georgia", bold: true, charSpacing: 5,
    color: C.white, align: "center", margin: 0
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  s.addText("Practical decision-making for upper limb imaging", {
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    fontSize: 13, fontFace: "Palatino Linotype", italic: true,
    color: C.sage, align: "center", margin: 0
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  s.addShape(pres.shapes.RECTANGLE, { x: 3.5, y: 1.22, w: 3, h: 0.025, fill: { color: C.gold }, line: { color: C.gold } });

  const principles = [
    {
      icon: "①", color: C.teal,
      title: "X-Ray is Always First",
      body: "Never proceed to CT or MRI without prior radiographs. X-ray is fast, inexpensive, gives structural overview, detects bony abnormalities, and guides further imaging choice."
    },
    {
      icon: "②", color: C.gold,
      title: "CT for Bone; MRI for Soft Tissue",
      body: "CT excels at fracture geometry, articular surface integrity, and surgical planning. MRI is the workhorse for tendons, ligaments, cartilage, labrum, nerves, and bone marrow oedema."
    },
    {
      icon: "③", color: C.sage,
      title: "Arthrography Unlocks Subtle Pathology",
      body: "Intra-articular gadolinium (MR arthrography) or contrast (CT arthrography) drives fluid into partial tears, revealing SLAP lesions, Bankart tears, TFC defects, and scapholunate injuries that plain imaging misses."
    },
    {
      icon: "④", color: "A0907A",
      title: "US for Tendons and Guided Therapy",
      body: "Ultrasound provides real-time dynamic assessment of tendons and allows simultaneous guided injection — an advantage neither MRI nor CT can match for de Quervain's, epicondylitis, or CTS."
    },
  ];

  principles.forEach((p, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    const x = 0.3 + col * 4.9;
    const y = 1.42 + row * 1.9;
    s.addShape(pres.shapes.RECTANGLE, { x, y, w: 4.55, h: 1.75,
      fill: { color: "162535" }, line: { color: "2A3F52", pt: 0.5 },
      shadow: { type: "outer", color: "000000", blur: 10, offset: 3, angle: 135, opacity: 0.2 }
    });
    s.addShape(pres.shapes.RECTANGLE, { x, y, w: 0.05, h: 1.75, fill: { color: p.color }, line: { color: p.color } });
    s.addText(p.icon, {
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      fontSize: 18, fontFace: "Calibri", bold: true, color: p.color, margin: 0
    });
    s.addText(p.title, {
      x: x + 0.55, y: y + 0.12, w: 3.85, h: 0.35,
      fontSize: 12, fontFace: "Georgia", bold: true, color: C.white, margin: 0
    });
    s.addText(p.body, {
      x: x + 0.15, y: y + 0.52, w: 4.25, h: 1.14,
      fontSize: 9.5, fontFace: "Calibri", color: "8A9BB0", margin: 0
    });
  });

  s.addText("Grainger & Allison's Diagnostic Radiology · Imaging Anatomy Vol. 3 (Bones, Joints, Vessels & Nerves)", {
    x: 0.5, y: 5.38, w: 9, h: 0.2,
    fontSize: 7.5, fontFace: "Calibri", italic: true, color: "3A5060", align: "center", margin: 0
  });
}

// ─── Write file ──────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/upper-limb-radiology/Upper_Limb_Radiology.pptx" })
  .then(() => console.log("✅ Presentation written successfully."))
  .catch(err => { console.error("❌ Error:", err); process.exit(1); });

Running Command

cd /home/daytona/workspace/upper-limb-radiology && node build.js 2>&1

Running Command

ls -lh /home/daytona/workspace/upper-limb-radiology/Upper_Limb_Radiology.pptx

The presentation built successfully at 2.9 MB with all 7 actual radiological images embedded. Here's your download:

Upper Limb Radiology
Presentation · PPTX

Here's what's inside the 9-slide deck:

Slide	Content
1	Title - Dark slate background with teal/gold accents, Georgia serif font, region list panel
2	The Three Modalities - Three comparison cards (X-Ray, CT, MRI) with muted teal/gold palette
3	Shoulder: X-Ray - Two actual X-ray images (enthesophyte + rotator cuff arthropathy) with clinical notes
4	Shoulder: MRI - Full-thickness cuff tear MRI + SLAP MR arthrogram side by side
5	Shoulder: AC Joint + Decision Guide - MRI image with a complete modality selection reference panel
6	Elbow: CT - Large CT arthrogram image (OA + loose body) with annotated key points
7	Wrist: MRI - TFCC tear MR arthrogram with dark cinematic layout, clinical breakdown
8	Disease-Modality Reference Grid - All 13 conditions across Shoulder / Elbow / Wrist in a clean table
9	Key Principles - Four principle cards on dark background, closing slide

Design choices: Deep slate-charcoal (#1C2B3A) dominant tone, warm parchment (#F5F0E8) for content slides, dusty teal (#4A8FA8) and antique gold (#B89A6A) accents, Georgia/Palatino Linotype for headings, Calibri for body text - all muted and easy on the eyes.

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