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Language of Radoiolgy


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Language of Radoiolgy

Ø Gas and Fat are BLACK in the X-ray.

Ø Muscle, Soft Tissues and Water are GRAY X-Ray.

Ø Bone and Metal are White in the X-Ray.

Motive Steps

Motive Steps are applied to every FILM that is being read.

  1. Identify the View.
  2. Office Motive: Why did the doc take the film? For example Lateral Cervical: Routine Screening films; Oblique films are to view IVF; Oblique Lumbar films are taken to view Pars & Facets; PA-Ulnar deviated of the wrist films are taken to view Scaphoid and Lunate.

Note: Cervical F/E Films are taken to check abnormal motion and/or fusion and also to check stability and instability of ligaments. These views are contradiction for fractures except for clay shoveler’s fracture, traumatic dislocation, Infection and Malignancies.

Rule: The only time you will see dislocated Facet on Flexion film is due to Rheumatoid Arthritis.

  1. Color Motive: How does the film appear?

Five Color Motives

A. Normal Colors

    1. Bone is White.
    2. Soft Tissue is Gray.
    3. Gas is Dark or Black.

B. Under-Penetrated or Under-Exposed

a.       Bone is WHITE.

b.      Soft Tissue is WHITE.

Note: Two reasons first this is a bad film and more important that it was taken for soft tissues.

Note: Always check the bones first in Under-penetrated film, if there is no problem in the bone or cannot see the bone, then go to and check Soft Tissues.

C. Overpenetrated or Overexposed Film

a.       Bone is Dark.

b.      Soft Tissue is Dark.

Note: Two reasons first is a bad film and more importantly why did doc take this film for one particular area? In the film don’t worry what can you see in the film, but more worry about what are you seeing in the film.

D. Bone Film

a.       Bone is White.

b.      Soft Tissue is Dark/Black.

Note: Bone films are not the first one to be taken, they are the 2nd or 3rd film.

v     Bone Films: Problem is in the Bone.

4. First Impression

Ø Normal VS Abnormal

Ø If you are distracted that means it is an abnormal film.

Ø If first impression abnormal, then you will go to the fifth motive step.

5. Second Impression

Congenital VS Acquired

Ø Congenital: Once you have a congenital anomaly on that film then you no longer worry, about alteration of color from Paget’s, Infection or Malignancies (Boards: MM or Lytic Mets), no longer worry settle fracture or settle dislocations.

Ø Acquired: The only time you will pick Acquired condition, once you have a congenital anomaly on that film is if the acquired condition is obvious enough to override the congenital anomaly.

Note: Lumbosacral Transitional Segment: TP Fracture in the lumbar spinous is obvious.

6. Normal Anatomy for AGE, SEX and DEFORMITY

Ø Age: It is the Biggest differential. If every Single vertebrae has growth center present at anterior superior portion of the vertebrae then patient is under 20. If every single VB has perfect square shape then patient is between 20-40 years of age. If signs of DJD are present then person is over 40 years of age.

Ø Sex: It is not important in the Spine, however, it is important in the Pelvis.

Ø Deformity: By definition, it is bending/twisting of bone with the cortex still relatively intact.

Deformity in the Spine

a.     Paget’s Disease

b.    Congenital Anomalies.

Deformity in the Extremities

a.       Paget’s Disease

b.      Fibrous Dysplasia

Lateral Cervical Film

Ø Office Motive: Routine Scout

ADI Space

Spinolaminar line of C1 in relation to C2.

Then come down infront of the Body.

Check the Base of the Dense for radiolucent lines.

Approximate the dense for height, alignment and color.

Check the vertebral bodies for alterations of shape and color.

Check the disc spaces for alteration of size and color.

Check Posterior Arch Balance.

Check the space between Occiput and Atlas and Atlas and Axis.

Check the Pedicle of C2.

Go down the BACK of the Bodied.

Check the Facets.

Check the Spinolaminar Lines.

Check the Spinouses.

Check the Soft Tissues infront of the spine.

1. ADI Space: If you see the ADI space you can immediately rule out AGENESIS of the DENSE.

Ø Increased ADI Space

I. Down’s Syndrome: Absence of Transverse Ligament of Atlas (joins Anterior arch of the atlas to dense)

II. Trauma



V. Psoriatic Arthritis

VI. Reiter’s Syndrome

ü Note: The most important result of Inflammation is Loss of Function and it also leads to Laxity of that ligament. Any condition that cause inflammation cause laxity which leads to increased ADI.

ü Normal ADI Space: Thin BLACK line.

If the width of the ADI space is similar to the width of the anterior tubercular, then you have an increased ADI on that film.

2. Spinolaminar Line of the C1 to C2 to check if the Atlas in place or displaced

q       If atlas is moved anterior, there is four possible reasons.

Increased ADI

Fracture Dense

Unstable Os Odontodium

Agenesis of the Dense.

q       If Atlas moves Posterior, there are three possible reasons.

Fractured Dense

Unstable Os Odontodium

Agenesis of the Dense

To check Atlas is in-place or displaced, draw straight vertical line along the back of the VB of the C2 that straight vertical line should hit some portion of the spinolaminar line of C1 for Atlas to be in-place. If it does, then determine if Atlas is gone Anterior or Posterior.

q       Os-Odontodeum

a)      Non-union of the Dense.

b)      Un-United Dense

3. Come Down Infront of the Body: Four Things

  1. Liping / Spurring of DJD and infections: don’t rule them in or out until you check the Disc Spaces.
  2. Hyperostosis: AKA “Candle Wax” Dripping, Anterior Spinal Bridging of four or more segments to indicate DISH. It doesn’t have to be 4 continous, but has to be in the same region. DISH: Calcification of ALL, Usually Preserve the Disc Space, Never involve the FACET interms of FUSION, Non-inflammatory
  3. Syndesmophytes
    1. Inflammatory Spurs
    2. Calcification of ALL or Annular Fibers of the Disc
    3. Body Response to the inflammation as Fusion (accumulation of the CA2+)

There is two types of syndesmophytes:

I. Marginal: AS – if calcification disappear, then it is marginal; “Egg-Shell” Calcification around the disc, if it does have it, then it is Marginal Syndesmophytes.

II. Non-Marginal:

Psoratic Arthritis

Reiter’s Syndrome

Note: If you see what appears to be hyperostosis, candle-wax dripping, anterior-bridging of disc, but the facets are fused, then it cann’t be DISH, then it ONLY you thing of PSORATIC Arthritis, REITER’S SYNDROME.

Avulsion Fracture/Compression Fracture

Cervical Spine: Teardrop Fracture – Avulsion Fracture of the anterior aspect of the vertebral body and bony fracture is appeared as tear dropping down. It is commonly seen around C2 region.

Compression Fracture: Lost of anterior body height 25% or more, then think about “MOPIT”: Malignancy, Osteoporosis, Paget’s Dx, Infection, and Trauma.

5. Check the Base of DENSE for Radiolunency Line

Ø If Line is present, then think about four possibilities.

I. Fractured Dense

II. Os-Odontodeum

III. Agenesis of the Dense

IV. “Mach” Line: Nothing more than a Shadow.

The way to prove that is the radioluncent is just a Mach line by ruling everything else out.

How to find the Base of the Dense: Locate TP of C2 and at the top you will find base of the Dense.

6. Proximate the Dense for Height, Alignment and Color

Height Approximation:

Height of the Dense is similar to height of C2 BODY. We are checking to see that if the Majority of the Dense is below the occiput to RULE OUT the condition called Basilar Invagination. If the majority of the Dense is above the occiput, then the Dx is Basilar Invagination and M/C causes of Basilar Invagination are:

Paget’s Dx

Fibrous Dysplasia


Chamberlin’s Line: Hard Plate to the Posterior Foramen Magnum. If it is less than or equal to 7 mm, the it is normal. But if it is greater than 7 mm, then it indicates Basilar Impression or Invagination.

Mcgregor’s Line: Hard Plate to the Base of the Occiput. If it is equal or less than 8 mm in male and 10 mm in female, then it is normal. If it is greater than 8mm male and 10mm in female, then it indicates Basilar Invagination or Impression.

Alignment: Come to the Front and Back to the Body of C2, check to see if dense is inplace or displace:

i. Fractured Dense

ii. Unstable Os-Odontodeum

Note: Os-Odontodeum usually not dx off a Lateral Cervical Film. However, if you see a

Tomogram with radiographic sign of a os-odontodeum, which is smooth & obvious cortical margins around the two fragments. If you see the obvious radiographic sign of os-odontodeum that is a BIG, THICK radioluency, which is smooth with cortical margins around two fragments.

Anytime you have a bone displaced from itself, you will assume to be fractured until proven otherwise. Two ways to prove otherwise:

Office Motive: It is not a film that the doc would have taken if that bone had fractured.

If you have the obvious radiographic sign of the Non-Union.

3. Color

Your are going to compare the color where the dense would be, in relation to the

color of anterior inferior part of the Body of C2. If the dense would be region is

WHITTER than the anterior-inferior aspect of C2, then RULE OUT Agenesis of the


Rule: Anytime that is penetrated on X-ray will appear DARKER; anything that is

not penetrated will appear WHITTER.

7. Check the VB for Alteration Shape & Color

Alteration of Shape: PFC: Paget’s Dx, Fracture, Congenital Anomalies.

Alteration of Color: Whiter VB –

i. Blastic Mets - >40

ii. Paget’s Dx - >50

n   If you see an IVORY white vertebra under the age of 30, then you should think of

Hodgkin’s Disease

n   If the vertebrae turns DARKER think of Lytic Mets and Multiple Myeloma

Rule: Color Change – Techanical VS Pathological

Technical color change the bone change one way and soft tissue follow.

Pathological color change Bone change one way, but soft tissue doesn’t follow.

The most common cause of IVORY WHITE vertebrae: Blastic Mets.

Rule: Any time you have a white density in a bone, other than the proximal femur head and carpal bone, you will assume it to be Blastic Mets until proven otherwise.

Five ways to prove otherwise:

1. Hx: Age of the patient

2. Lab Tests: Alkaline Phosphalte if normal no blastic.

3. Bone Scan: Normal No Blastic Mets, if hot bone scan then it is sign of Blastic Mets.

4. Biopsy

5. If you see obvious radiographic signs of the cortical thickening of enlargement or deformity of bones to indicate Paget’s disease.

Paget’s Disease: Radiographic Signs

By the time VB is Ivory White due to Paget’s Dx, it will obviously larger cortical thickening causes enlargement.

The earliest X-ray sign of Paget’s Dx in the spine is known as “Picture Frame” vertebrae.

When Checking for enlargement, check vertical and horizontal enlargement for Paget’s Disease.

7. Disc Spaces for Alterations of Size & Color

Two Big Problems:


a.       Decreased joint space

b.      Subchondral Sclerosis AKA Ebernation

c.       Liping/Spuring


Note: DJD affecting the Body & Disc AKA Discogenic Spondylosis

DJS VS DDD: reality they are same!!!

Five Secret Questions

What is the Color?

What is the Location?

What is the Age?

What is the Shape?

What is the Sex?


“Vacuum Phenomena”: Most Commonly seen with DJD & Trauma.

Radiographic Sign of Infection

Decreased Joint Space

Joint Space turn Whitter.

Most important sign is destruction of bone on both sides of joint.

ONLY condition gets into a joint space and destroy bone on the both sides of the joint.

8. Check Posterior Arch of Atlas

Absence of Posterior Arch of Atlas

Cut away due to surgery, so look for signs on the films.

Eat away to the malignancy.

Congenitally absent AKA Agenesis of the Posterior Arch of Atlas; Posterior tubercle is presented.

Before you put down agenesis of the posterior arch as dx, check to see if posterior arch is fused to occiput in occipitalization.

Vertical Radioluencies of Fracture

Jagged radioluencies.

Usually No cortical margin around the two fragments.

There will be Displacement.

Vertical Radioluencies of Non-Union

RL is smooth

Usually you will see cortical margin around two fragments

there will be NO displacement.

Radioluneny passing Horizontally through Posterior Arch of Atlas It is a “Mach” line.

9. Check Space between C0-C1 and C1-C2

If it is unequal, it is indicates we got problem.

10. Check Pedicle of C2

Ø      Check it for vertical Radioluency C2 fracture on that film Hangman’s Fx, usually extensive extension caused by Whiplash.

Ø      Non-Union only occur at areas of the growth center.

Ø      Pedicles don’t have growth center.

Ø      There is Three primary Ossification center one in the body and one in the each lamina.

Ø      There is Five secondary Ossification center one in each endplate, one in each TP and one in the Spinous.

Ø      Type IV Spondylolisthesis is AKA Hangman’s Fracture.

11. Come Down to the Back of the Bodies

Look at overall curve

decreased in Posterior height & body destruction to indicate Malignancy Malignancy as a Dx if there are no other sign of Infection or Trauma on that film.


Malignancy: Loss of anterior and posterior body height.


- You get wedge shape vertebrae.

- Loss of anterior body height.

- Preserve the Posterior body height

Paget’s Disease:

- Cortical Thickening.

- Deformity of the Bone.

- Enlargement of the Bone.

Infection: destruction of bones on the both sides of the joint

Trauma: Bony Fragment, Bony Debris V-Shaped Defect. If you have compression fracture due to trauma call it compression fracture and if you have compression due to any other cause then it is called it Pathological compression fracture.

Slipping/Sliding of Subluxation (anterior or retrolisthesis) or Dislocation

Subluxation: up to 10% slippage of one vertebrae on the other with the facet still in line.

George’s Line: Drawn along the Back of the VB.

Dislocation: 25% slippage of one vertebrae on the other with facet overriding or parching. Dislocation is Immediate referral for surgery.

AS soon as you see fanning of the spinous, there is dislocation Tear four ligaments.

Superspinatous Ligament

Intraspinatous Ligament

Ligamentous Flavum

Capsular Ligament


Between 10%-25% Look for Fanning of the Spinouses, if present, then is dislocation.

No Fanning Subluxation.

12. Check the Facet

Dislocated: - RA & Trauma

Destroyed: RA & OA

Fused: RA & AS

“Teeth Marks” appearance in the joint RA

Decreased joint space & Lipping/Spuring of the joint OA

RA & AS @ the front of the Body Marginal Syndesmophytes AS

Non-Marginal Syndesmophytes RA

13. Check the Spinolaminal Line

Look for Spinolaminal line

Missing Spinolaminal Line = Spina Bifida Occulta = Spondylochesis Decreased Folic Acid in the first trimester.

M/C seen in C1, C6, C7 in the cervical spine.

Folic Acid dose for expected pregnancy is 800 mg.

14. Check the Spinouses

Absent Spinous

Cut away due to surgery: Look for signs of surgery.


Congenitally absent

Note: Absence of 1, 2 spinouses Keep Congenitally absent. Absence of 3 or

more spinouses keep as surgical removal.

Spinous is Present: Spinous fracture in the cervical area M/C known as Clay-

Shovelar’s Fracture at C6, C7, T1. Mechanism of injury for Clay-Shovelar’s

fracture is extensive Flexion.

Rule: 50% of the time when you have a posterior pinticle, you have Clay-

Shoveler’s Fracture.

15. Check Soft Tissues infront of the Spine

Retropharangeal Space Infront of C4 ≤ 7mm

Retrolarngeal Space infront of the C5 ≤ 14mm

Retrotracheal Space infront of C6 ≤ 22 mm in adult and ≤14 mm in child under the age of 13.

Most common causes of soft tissues Swallowing:




Note: In all if the width of the soft tissue is wider than the width of vertebral body, then you have soft tissues swallowing.

Rule: In order to diagnosis an infection on a lateral cervical film and soft tissue can be visualized, you must see soft tissue swallowing.

n    If you are seeing IVF cervical appearance due to one of three possible regions:

Fusion of Facet

Excessive Rotation of the Facets


► “Wasp Waist” Deformity → Pathanomic of Congenital Block.

Go to the anterior aspect of the disc space and draw straight vertical line and ask yourself that do I see Bulging Infront of that line → if answer is YES → Acquired Block and if answer is NO → Congenital Block.

► Go and check the Facet if they are fused together → How many spinouses do I see, how many spinolaminal line are present.

♣ If two spinouses and one Spinolaminal line → Congenital

♣ Two Spinous, two Spinolaminal lines → Acquired

♥ If you see decreased body height on a AP Film, Posterior Body height is decreased ? ? /

► Horizontal Radiolunency going through vertebrae is a “Mach” line, not a fracture.

Hemisphricalsphenydloscalorosis: associated with Discogenicspondylosclorosis and uncinate arthrosis more specifically.

► Cervical F/C will be read identically to lateral cervical, only difference is office motives.

Cervical Flexion and Extension Film

Posterior Restraining Ligament

Transverse Ligament

ADI Space shouldn’t change from Neutral Lateral through the cervical F/E film, if this does change then you have laxity → laxity contridictatory to Adjustment.

► The Best view to diagnose Occipitalization is cervical flexion view.

► Multiple Congenital blocks in one region, it is called Kalip-Feil Syndrome.

► Congenital Block vertebrae AKA:

Failure of Segmentation


► As in the Spine:

Marginal Synesmophytes

Egg-Shell appearance in the joint

► Any condition that increases the blood supply to the bone will turn the bone DARKER and any condition that cut off the blood supply of the bone will turn the bone WHITTER.

► All the inflammatory condition will cause osteopenia.

► Hyperthyroidism: destroy bone → bone will become DARKER.

► Multiple calcified Lymph nodes → severe Infection.

If you have fusion due to Surgery it is known as Arthrodesis

If you have fusion due to pathology it is known as Anklosis

► AS spreads as follow:


Thoracolumbar Region

Cephalically and caudally

Part IV → Look for AKA, then Radiographic Findings and then go to DDx.

► Dense Fracture AKA Anterior Displacement of the Atlas.

► Infections is the only condition that gets into the joint and destroy the disc.

► Malignancy grow with the help of blood, therefore, Malignancy NEVER cross joints

because joints are avascular.

►Rule: ONLY TWO Conditions EAT BONE;



Note: Look at the nearest joint, if destruction is present at one side of the joint, then it is malignancy, if both sides are involved then it is Infection.

Psoriatic and Reiter’s Syndrome

Non-Marginal Syndesmophytes

Fusion of the Facets at the same levels.


Office Motive: Taken to view DENSE and ARCHES of ATLAS.

Check to see if dense is present.

Check the structures creating (arches of atlas) MACH line.

Check the base of the dense.

Outline the dense to see if it is inplace or displaced.

Paraodontoid space checkup

Check Lateral Mass of C1 with respect to the body of C@ for OVERHANG.

Check Lateral Mass of C1 for alteration of shape and color.

Check the TP of Atlas for alteration of shape.

Check the body of C2, C3 for alteration of shape and color.

Check the Disc space between C2-C3, for alteration of size and color.

Check the Arches of Atlas, Spinous of C2, C3 for vertical & Horizontal radiolucency.

Check the Soft Tissue in and around the Jaw.

Rule out/in Agenesis of Dense

Check the Structures Creating (arches of atlas) MACH line

a.     Atlas Arches Similing” - Posterior

“Froning”- Anterior

b.      Occiput

c.       Teeth: vertical RL through are not fx, they are MACH lines produced by the teeth.

→ dense fx produces horizontal RL.

Base of the Dense

► If you see radiolucency line through the base of the dense.

v     Thick & Smooth: Os-Odontodeum

v     Thin: Dense Fracture

Inplaced VS displaced Dense: refer as “tilting or Leaning” odontoid.

Tomogram: Blurred Out Film.

a.       Thin radiolucency is fracture above the base of the line.

b.      Fx at the base of the dense.

c.       Fx below the base of the line.

Note: a & c are stable fracture; b is the M/C and most unstable. Therefore, it is the most severe fracture.

All three types refer out after putting collar.

5. Paraodontoid Interspaces to see if they are unequal or enlarged → that means 

there is possible Jefferson’s Bursting Fracture

6. Check Lateral Mass of C1 with respect to the body of C2 for


Ø To check for overhang, go to the lateral aspect of body C2, draw straight line upward if lateral mass of C1 does cross that line, then overhang is present.

Ø Once overhang present on one side: three scenarios present:

I.            Overhang on one side, but that overhang to be normal, the lateral mass on the opposite side must shift in equal amount → normal that means atlas Lateralization and adjust it.

II.         Overhang on one side, but lateral mass on the opposite side didn’t shift equal amount → Jefferson’s Bursting Fracture.

III.       Overhang on both sides → Jefferson’s Bursting Fracture → M/C cause of Jefferson’s Fracture.

7. Check the Lateral Masses of C1 for Alteration of Shape and Color

Ø Alteration of Shape is PFC

Paget’s Dx


Congenital Anomalies

Ø Alteration of Color

Whiter Blastic Mets & Paget’s Dx

Darker → Lytic Mets & MM

8. Check the TPs of Atlas for Alteration of Shape

Ø Congenital Anomalies

a.       Epitransverse Process: Superior aspect of TP up to the occiput and creates pseudoarticulation at the occiput.

b.      ParaCondylar or Paramastoid Process: This comes down from the occiput toward the superior aspect of the TP and creates Pseudoarticulation at the the superior aspect of the TP.

Check Body of C2, C3 for Alteration of Shape and Color

Ø Alteration of Shape is PFC

Paget’s Dx


Congenital Anomalies

Ø Alteration of Color

Whiter Blastic Mets & Paget’s Dx

Darker → Lytic Mets & MM

10. Check Disc Space for Alteration of Size and Color


Decreased disc space

Subcondyalar Sclerosis


Ø Infection

Destruction of Bones on Both Sides.

11. Check the Arches of Atlas, Spinous of C2, C3 for Vertical &

Horizontal Radiolucencies

Ø Spina Bifida Occulta it is vertical radiolucency Spondylochesis

Ø Spinous fracture of C2, C3 Horizontal Radiolucency.

12. Check Soft Tissue in and around the Jaw

Ø BIG Thing → Lymph Node Calcification

Ø Never put down Blastic, Lytic Mets, MM or Paget’s on APOM unless you are willing to bet your life!!!!

Ø BIG, THICK Radiolucency above the Base of the Dense, this is known as Os-Terminale.

C2 Burst Fracture: Verticle lucency going through a bone with a break in the cortex at both ends → separation occurs.


Office Motive: Routine Scout Film.

v     Never Spina Bifida of C4 unless you are willing to bet your Life !!! It is a ‘Mach’ line created by the laryngeal shadow.

Find the last set of TP that points upward, which is T1.

Then check to see C7 TP.

If you see what appears to be a rib articulating with C7 TP, then you Dx as cervical rib Can be unilateral or bilateral.

v     Enlongated Hypertropic TPs of C7: Draw a line at the lateral aspect of the T1 TP and see if C7 TP cross that line.

v     Cervical rib: Patient with cervical rib suspectable to neurovascular compression seen in TOS.

v     TP Fractures are very rare.

Check the vertebral body for alteration of Shape and color.

v     Techanical VS Pathological

v     Pedicle best seen on Oblique Views.

Check disc spaces and uncinate for Alteration of Size and Color.

v     DJD: three things are possible.

a)      Decreased Joint Space

b)      Subcondylar Sclerosis

c)      Spurring/Lipping

Ø Infection: Destruction of Both sides of the joint.

Ø Uncinate: “Bate-Ear” Appearance → Normal.

If uncinates are Flatten → “Blunting” of the uncinate which is indicative of uncinate Arthrosis AKA uncinate Hypertorpy.

Check Spinouses

Ø Spina Bifida of Spinous

Ø Check for Horizontal Radiolucency to indicate a Spinous Fracture.

Ø “Double-Spinous” Sign: Indicative of Clay-Shoveller’s Fracture.

Check Tracheal Air-Shadow

Ø Check for Deviation

Ø Never Make Long Patholgoy diagnosis on any other film OTHER THAN A CHEST film

Ø Part IV can have follow-up question!!!

  1. Check the Soft Tissue on both side of the Spine

Ø Lymph Node Calcification VS Carotid Artery Calcification

Ø Vertebral Artery Rarely Calcified.

Ø Calcification in the Shape of V → Carotid Artery Calcificaton

Ø If you see one Round & White Density, it is either lymph node calcification or carotid artery calcification.

Ø But if you have more than two or more round & white Densities, then try to line them up in straight vertical line, if you can then it is Carotid Artery Calcification and if you cannot then it is Lymph Node Calcification.

Oblique of Cervical Spine

Office Motive: To see IVF.

NEVER put down occipliztion on oblique film as diagnosis.

We need to know which IVF we are looking at:

RPO → Left IVF

LPO → Right IVF

Cervical Anterior Oblique → Same Side IVF

Cervical Posterior Oblique → Opposite Side IVF

What level are the IVFs?

First IVF between C2-C3

Anatomy of IVF
  • The anterior border of IVF is formed by the body of uncinate.
  • Superior, inferior borders are pedicle.
  • Posterior borders are Facets

Steps to Read the Oblique Film

Starts at the top to the bottom compare the size of one IVF to the other.

Only two things an happen to a Hole.

Small Hole: Suspect IVF encroachment; must see pinching in the middle. IVF encroachment → Don’t Cause Rotation.

Big Hole: 3 possible reasons:

i. Lytic Mets → Rare in Cervical Spine

ii. Agenesis of Pedicles

iii. Neurofibroma:

q       Tumor of a nerve root.

q       Very Expansile Tumor.

q       Correct it via Surgical Treatment

q       “Dumbbell” Shape IVF: useless radiographic sign.

q       Van_Recklinghausen” Diagnosis: Multiple Neurofibromas

q       “Café-ale Spots”: Borders are nice and smooth → appears as “Coast of California”; (“Coast of Maine” → Fibrous Dysplasia).

ü Note: For ii and iii, draw a straight & vertical line → Do I see scalping of back posterior body, if answer is YES → Neurofibroma and if answer is NO → Agenesis

ü of Pedicle.


AP Thoracic Film

Ø Routine Scout Film

Ø It will be read IDENTICALLY to a AP Lumbar Film in terms of Square Head Vertebrae System.

Lateral Thoracic Film

Motive: Routine Scout Film.

Four Steps to this process:

Come Down infront of the bodies

I. Lipping/Spurring of DJD or Infection; don’t rule in/out until we check the disc spaces

II. Hyperostosis, “Candle Wax” dripping, anterior bridging of four or more levels.

III. Marginal Sydesmophytes of AS

IV. Check of Avulsion Fracture or Compression Fracture

Check VB For Change of Shape & Color

Ø Alteration of Shape is PFC

Paget’s Dx


Congenital Anomalies

Ø Alteration of Color

Whiter Blastic Mets & Paget’s Dx

Darker → Lytic Mets & MM

Check Disc Space for Alteration of Size & Color

DJD: three things are possible.

a)         Decreased Joint Space

b)        Subcondylar Sclerosis

c)         Spurring/Lipping

Infection: three things are possible

a)           Decreased Joint Space

b)           Spurring/Lipping

c)           Destruction of Both sides of the joints.

Come Down to the Back of the Body

Ø        Look at the overall curve

Ø        Decreased Posterior Body Height and Posterior Body Destruction to indicate a Malignancy; if there is no other signs of Infection or Trauma on that Film → Then the diagnosis is Malignancy.

Ø        Multiple Myeloma: It can cause decreased Posterior Body Height; check 2-3 segments above and 2-3 segments below, and then you don’t miss MM.

Ø        Slight Loss of Anterior Body Height: 3 possible conditions come to mind.

i. Mild Compression: It don’t cause multiple endplate irregulaties.

ii. Infection: With infection, the destruction with joint space to joint space grossly unequal.

iii. Suheremann’s Disease: With Scheremann’s Disease, destruction from joint space to joint space relatively equal.

Radiographic Signs of Sucheremann’s Disease

Ø Slight Loss of Anterior Body Height of One or More Vertebrae

Ø Multiple Endplates Irregularities of Three or More continuous vertebrae

Ø Destruction From joint space to joint space is relatively equal.

Ø If severe enough, you get increase in Kyphosis

Ø Typically seen between 10-15 years.

Ø Equally seen in both sexes

Ø Equally Necrosis of your secondary growth centers specifically your endplates: trauma is the cause of Sucheremann’s Disease.

Ø Untreated AVN leads to early DJD; the best imaging to dx AVN is MRI; if you cannot order MRI then order BONE SCAN.

Ø Schmoral Nodes VS Nuclear Impression

Ø Schumoral Nodes

Usually occur on the anterior half of your vertebrae; anterior superior & anterior inferior

Ø Nuclear Impression

Usually occurs on the Posterior half of the vertebrae

Usually on the Inferior aspect.

“Cupid-Bow” Deformity: Nuclear Impression appears on AP Film.

Note: If you see 1-2 Schamoral’s nodes → ; 3 or more Schumoral’s nodes → Change your dx to Scheurmann’s Disease.

Lateral Lumbar Film

Office Motive: Routine Scout Film.

Come Down Infront of the Body

a)         Lipping/Spurring of DJD or Infection

b)        Don’t rule them in/out until you check the disc spaces

c)         Hyperostosis, Anterior Spinal Bridging, “Candle-Was” Dripping → DISH

d)        Marginal Syndesmophytes of AS

e)         Avulsio & Compression Fracture

Check the VB for Alteration of Shape and Color

Ø Alteration of Shape is PFC

Paget’s Dx


Congenital Anomalies

Ø Alteration of Color

Whiter Blastic Mets & Paget’s Dx

Darker → Lytic Mets & MM

Check Disc Space for Alteration of Size & Color

DJD: three things are possible.

d)        Decreased Joint Space

e)         Subcondylar Sclerosis

f)          Spurring/Lipping

Infection: three things are possible

a)           Decreased Joint Space

b)           Spurring/Lipping

c)           Destruction of Both sides of the joints.

Come Down to the Back of the Body

Ø        Look at the overall curve: Lordotic – Normal.

Ø        Decreased Posterior Body Height and Posterior Body Destruction to indicate a Malignancy; if there is no other signs of Infection or Trauma on that Film → Then the diagnosis is Malignancy.

Ø        Slipping/Sliding of a Subluxation of Anteriolesthesis, Spondylolesthesis.

Check The Pedicles

Ø        Biggest Thing is to check is Pedicle Fracture.

Check The Pars

Ø Biggest Thing is the Affect the Pars is Fracture

Ø Find Pars: Go to the Base of the Pedicle move back Posteriorly where Pedicle meets the facet, draw 45° line and it is the Pars Intercularis.

Ø Pars Fracture without Anterior Slippage → Called it Spondylolysis.

Check Spinouses

Ø Check if Spinouses are Present.

Ø If they are Absence: 3 possible reasons

I. Surgical Removal

II. Malignancy

III. Congenitally Absence

Note: Usually Lumbar spinouses are OVERPENATRATED, so they are not visible.

Lumbar Surgery: If you are missing spinous, look for myelogram remnant on the film, it most likely is surgery.

Check the Soft Tissue In front of the Spine

Ø        Abdominal Aorta in front of the L2, L3, L4.

Ø        No more than 3.8 cm

Ø        3.8cm abdominal Aortic Aneurysm is present.

Ø        5.0 cm referral for Surgery.

Ø        The normal width of the abdominal aorta is 1/2-3/4 of the width of Lumbar Spine.

Ø        Therefore, if the width of the abdominal aorta is wider than the width of the Lumbar spine → then dx is Abdominal Aorta Aneurysm.

Ø        Radiographic Sign AAA

a.       Half Moon Shape

b.      Curve-Linear Calcification

“FLAT” Vertebrae: AKA

I. Vertebral Planae

II. Pancake Vertebrae

III. Coin on Edge Sign

IV. Wrinkled Vertebrae Sign

Lumbus Bone VS Avulsion Fracture


n    It is like Non-union

n    Radiolucency usually smooth

n    Usually you will see cortical margins around two fragment, but no there will be NO displacement

n    Assume bony fracture to be limbus bone

Avulsion Fracture

Usually Jagged Radiolucency

Usually there is no cortical margin around two fragments

It will be displaced with Avulsion Fracture

Note: To check for displacement, draw straight vertical line in front of VB, if bony fragment status in the line in front of VB, if bony fragment stays with in the line → Limbus. If Bony Fragment Crosses → it is Avulsion Fracture.

When you are differentiating with Limbus and Avulsion, keep your answer as Limbus.



Ø “Bamboo Shoot” Spine

Ø Every Single segment that affected that AS, the marginal syndesmophytes bilateral and symmetrical.


Type IDysplastic: Congenital Anomaly causing Slippage.

Type IIIsthmic: Pars Fx casuing the Anterior Slippage; also known as Spondylolytic


Type IIIDegenerative: Usually DJD of the facet causing Anterior Slippage; AKA

Non- Spondylolytic Spondylolisthesis.

Type IVTraumatic: Pedicle Fx Causing the Anterior Slippage.

Type VPathological: Usually you have pathology such as Lytic Mets, MM cause

compression of VB, resulting in the Anterior Slippage.

Note: If you have inverted nepolan-Hat sign that means you have grade 3 or more Spondylolisthesis.

On AP film: Radiographic Finding of Spondylolesthesis

a.       “Inverted Napolian-Hat” Sign.

b.      “Bowel-Line”

c.       “Brail-Ford”

d.      Gendarne Cap”

Anterolisthesis: It cannot explain why VB went anterior.

Meyerding Grading System

Grade I 1% - 25% Slippage

Grade II 25% - 50% Slippage

Grade III 50% - 75% Slippage

Grade IV 75% - 100% Slippage

Grade V → >100% Slippage

Ferguson’s Sacral Line

Alman’s Line

L5 vertebrae has slipped > 100% has dropped down in front of sacrum Known as Spondyloeptosis.

If you are right at the border between two grades, ALWAYS go with the lower #.

Buttersing Phenomena: Spurring seen on sacrum, body trying to fuse to stabilize spondy.

Oblique Lumbar Film

View the Pars & Facets

On Posterior Oblique same side Pars & Facets

On Anterior Oblique opposite side Pars & Facets

Markers always go behind

Anterior → Behind


Scotty Dog

EyeEpilateral Pedicle

NoseEpilateral TP

NeckEpilateral Pars

EarEpilateral Superior Atricular Facet

BodyEpilateral Laminae

Front LegEpilateral inferior Articular Facet

Back Leg → Opposite Inferior Articular Face

Tail → Opposite TP

“Collar Sign” If “Scotty dog” has Black Collar around his/her neck refer to as an indicative of Pars Fracture.


Biggest thing affecting the PARS will be Pars Fracture Spondylolesis.

Oblique Film: You cannot see anterior slippage on oblique film.


Biggest condition is seen on Oblique Film is called facet subcondylar Sclerosis.

Mcnab’s Line

Drawn along the inferior aspect of the vertebral body. You are checking to see if the superior articular facet of the vertebrae crosses that line, if it does, then it is POSITIVE Mcnab’s line indicative of Facet Subcondylar Sclerosis and if answer is no then facets are normal.

AP Lumbar Film

Body → Face

Eyes → Pedicles

Nose Spinous

Ears → Transverse Processes


Ø Vertical striation in a vertebrae → called Hemingioma.

Ø “Hemi-Vertebrae”

Ø “Butterfly” vertebrae

Ø It can turn Whitter:

I. Blastic Mets

II. Paget’s Disease

Ø It can turn Darker

I. Lytic Mets


Ø “Crushed” Vertebrae → Malignancy: Only dx if there is no sign of Trauma & Infection.


“Missing” Pedicles: 1. Lytic Mets 2. Agenesis of the Pedicle

When you see a missing pedicle, First assumption is due to Lytic Mets. For Part IV – Lytic Mets AKA “Owel-Winkling” Sign.

Note: For you to change from lytic mets to Agenesis go to the opposite pedicle ask yourself a question → Is the opposite pedicle is more thick & sclerotic and Whitter than one above and one below → Yes → Agenesis of the Pedicle; if answer is No → Lytic Mets.

Multiple Myeloma

Decreased Posterior Body Height, but it spares the Pedicles → “MM-Pedicle” Sign

By definition MM is Plasma Cell Leukemia.

Medulla has more Plasma cells, majority found in the bone marrow and Plasma cell makes AB.

Laboratory Tests Positive for MM

Ig-M Spike

Reverse A/G Ratio

Benes-Jones Proteinuria

Normocytic-Normochromatic Anemia

Rouleaux Formation → Blood Smear → RBC Stack up Against Each other.

Increased ESR


Ø Check if the Spinous if present or absent

Ø If it is absent: Then there is three possible reasons.

a.       Cut away due to Surgery

b.      Malignancy

c.       Congenitally Absent

Transverse Processes

Biggest thing those TPs are Fractures.

TPs & Non-Union can be unilateral or bilateral

Radiographic Signs of Fracture

Usually “Smooth” Radiolunency

Usually there will be cortical masses around the two fragments, there is no displacement.

The only time you will put down a TP fx as a dx without displacement is if you see a bony callous.

AP Lumbar Film

Start of 1/3 of the SI joints

Compare one ilium to the other for alteration of shape & color.

Check for “Risser” Sign

Going to go to the top of the iliac crest and draw a line across, it should bisect L4, L5 disc space.

Count up the lumbar spine until you find the last set of ribs that point down which you will assume to be T12.

Count down the lumbar spine checking for lumbosacral transitional segment

Check the sacrum for alteration of shape and color & for vertical radioluencies.

Check L5-S1 Facet for Tropism.

Perform Sequare Block Head System all the way up to the spine. Check the disc spaces all the way up to the spine

Check opposite the L2 vertebrae Renal Artery Aneurysm.

Check L2-L4 for AAA.

Check the Soft Tissue from the Rib 12 down to the iliac crest bilaterally

Check the ST of the Pelvic in-let

Start of 1/3 of the SI joints

Check for three possible conditions.




ü Note: When checking the lower 1/3 of the SI joint the first thing you ask can I see joint spaces → Yes → Rule out AS, Because AS causes bilateral fusion of the SI joints. Before you say that it is AS → Technical reasons VS Pathological reasons

When you see bilateral symmetrical Whitening of iliac side of the SI joints:



To Differentiate DJD from OCI

Compare the color of the ilium to the lower portion of the sacrum of the SI joints

If the color of the ilium is similar to the lower portion of sacrum of SI joint → Dx is DJD.

If the color of the Ilium is obviously WHITTER then the lower portion of sacrum of SI joint → OCI.

OCI: Bilateral stress hypertrophy of the ilium → usually seen in women in the age of 20-30 with multiparous women; benign self-limiting, self-resolving → respond very well to chiropractic care.

When sacrum is present, in the film, move in little bit to compare color.

Triangular Sclerosis: Associated with OCI; not always present sign.

#2 Compare one ileum to the other for Alteration of Shape and Color

Ø Alteration of Shape is PFC

Paget’s Dx

Fibrous Dysplasia

Ø Alteration of Color

Whiter Blastic Mets & Paget’s Dx

Darker → Lytic Mets, MM & Benign Bone Tumors

#3 Check for “Risser” Sign

Ø Tell you about the Age of the Patient.

Ø It is found between the iliac epiphysis and iliac crest

Ø If you look at the Ressier Sign: Four possible Situations

Thin, Black line → < 20 years

White line → 20-30 years

Non thin, white line → 30-40 years

DJD & no line → > 40 years

#4 Going to go to the top of the iliac crest and draw a line across, it should bisect L4, L5 disc space

Top of the iliac crest draw a straight horizontal line across Line should bisect L4-L5 disc space.

#5 Count up the lumbar spine until you find the last set of ribs that point down which you will assume to be T12

#6 Count down the lumbar spine checking for lumbosacral transitional segment

Ø If you count 6 lumbar vertebrae then you have lumbarization of L1.

Ø If the L5 TP fused articulating with sacrum then you dealing with Sacralization of L5.

Ø When L5 TP is flatten or appears wider than normal, then refer to as “Speculated” TP.

Ø Never Pick subcondral Sclerosis with Pseudojoint.

Ø Always Pick Subarticular Sclerosis with Pseudojoint.

Ø Hypertropic or Enlargement of L5 → Congenital Anomaly; Part IV: They will call it “Speculated” TP.

Ø Sacralization: Even though there is NO “Speculated” TP

#7 Check the sacrum for alteration of shape and color & for vertical radioluencies

Ø Alteration of Shape is PFC

Paget’s Dx

Fibrous Dysplasia

Ø Alteration of Color

Whiter Blastic Mets & Paget’s Dx

Darker → Lytic Mets, MM & Benign Bone Tumors

Most common Gaint Cell Tumor of the Sacrum.

Check for vertical radiolucencies for SPINA BIFIDA for SI.

#8 Check L5-S1 Facet for Tropism.

AP → No joint Space

AP → If you see a joint space → Dx is joint space

No such thing bilateral facet

Tropism AKA Asymmetrical Facet

#9 Square Block Head System

Ø Disc Spaces



Marginal Sydesmophytes – AS

Ø For every single segment which is affected by AS, marginal syndesmophytes must be bilateral

#10 Check Opposite the L2 Vertebrae

Ø Check opposite the L2 vertebrae for:

a.       Renal Artery Calcification

b.      Renal Artery Aneurysm

Ø If you see “cheerio” sign → smaller than L2 vertebrae, it is Renal Artery Calcification.

Ø If you see “cheerio” sign → Larger than L2 vertebrae then you are looking at Renal Artery Aneurysm.

#11 Check L2-L4 for AAA

Ø Always Check Bilaterally

Ø Look for half-moon shape curvilinear calcification of abdominal aortic aneurysm

# 12 Check the Soft Tissue from 12th Rib down to the Iliac Crest Bilaterally

Ø Looking for:

a.       Gall Stones

b.      Kidney Stones

c.       Stack horn Calculi

Ø Most Gallstones are found only on the right side

Ø Kidney Stones

Calcium → see them on X-ray at L1, L2 level

Round, white density

3 basic types: Ca2+ Oxlate (M/C), Ca2+ Marate, Ca2+ Phospahte.

Can be unilaterally or bilaterally

Ø Gallstone more Laterally around L2 area

Ø Renal Artery calcification more medially around L2 area

Ø Renal Artery → Black surrounding by White.

Ø Stack Horn Calcification

Can be unilateral or bilateral

Must differentiate from IVP study


# 13 Check the Soft Tissues of Pelvic In-Let

Burst Fracture → Draw a line

→ measure inside the pedicle too!!

OCP: Osteitis Condena Pubi

DJD → mostly in the synovial joint; DJD in the Pelvis is very rare

If you see what appears to be DJD of Symphysis Pubis → OCP → due to prostate Surgery and Child Birth.

OCP is bilateral and Symmetrical

Blastic Mets are unilateral and unsymmetrical

“Claw-Osteophytes”: continous cortical margin; indicative of DJD in the Lumbar

Ankylosing Spondylistis

Romanus” lesion → Erosion on the bone

“Shinny-Corner” Sign

“Bamboo” Spine appearance due to the marginal syndesmophytes

Trolly Track” sign due to calcification of capsular ligament

Daggger”sign of AS due to calcification of supraspinatus and intraspinous ligament

“Star” Sign of AS only seen when the SI foints are fused

“Ghost” joints → fused SI joints →cannot be seen

Butterfly Vertebrae: Failure of ossification of the center of the vertebrae called saggital-clift defect.

Rudimentary Disc: AKA Remnant disc.

Non function see it with congenital block vertebrae

Knif-Clasp Deformity

Ø Spina Bifida of S1 with enlongated Spinous of L5

Ø Clinical picture compression, over sacral defect, sacral nerve irritation

Congenital Anomaly

Knif-Clasp Deformity

Lumbosacral Transitional Segment

Facet Tropisum

Spina Bifida of L5 & S1

Hypertrophic TP of L5


Rib: Post parts come down and anterior curve back up toward the spine.


Ø Office Motive: For Pain or Dysfunction

Ø Age is the BIGGEST differential in the Pelvis.

i. When you look at the growth center and they are open (Thin Black Line) – person is Under 20.

ii. When you Look and see a Thin White Line _ 20-30 years.

iii. No Thin white line, no signs of DJD – 30-40 years.

iv. Signs of DJD - >40 years

Ø 4 Growth Centers you should check for:

Acetabular Epiphysis

Ischiopubic Epiphysis (closes by age 9)

Femoral Capital Epiphysis

Greater Trochanteric Epiphysis

Young  Older Both

- Legg Calve Perthes - Lytic mets - Fibrous Dysplasia

- Slipped Capital Femoral - MM - Congenital Hip Dysplasia

- Epiphysis - Blastic Mets

- Paget’s


- Osteoporosis

- RA

- AVN of the Hip

Ø Anytime you have a Pelvic Shot in someone under 20 – 2 Conditions you must Look for:

i. Legg Calve Perthes

ii. Slipped Capital Femoral


Start off at lower 1/3 of SI joints.

Check Inner portion of Pelvis, Periosteum and Cortex.

Check outer portion of Pelvis, Periosteum and Cortex.

Draw line from Ilium to Isheum checking to make sure some portion of femoral head is inside the acetabulum.

Check the sex of the patient.

Check Color and Shape of one Pubis to the other.

Check Color and Shape of One Isheum to the other.

Compare proximal femoral head and acetabulum to the other side for alteration of size and color.

Compare Femoral Neck and Shaft to the other side for alteration of shape and alteration of color.

Check soft tissue of Pelvis Inlet.

1) Start off at lower 1/3 of SI joints

Ø Concerned with:

i. AS

ii. DJD

iii. OCI

Check Inner portion of Pelvis, Periosteum and Cortex.

3) Check outer portion of Pelvis, Periosteum and Cortex

4) Draw line from Ilium to Isheum checking to make sure some portion of femoral head is inside the acetabulum

Ø If Femoral Head is outside acetabulum:

i. Congenital Hip Dysplasia (unilateral or Bilateral)

Puttis Triad

Smaller than normal femoral Head (hypoplastic femoral head)

Shallow Acetabulum

Femoral Head will be outside acetabulum.

ii. Hip Dislocation

Femoral Head will be normal size

Acetabulum will be of normal depth

Femoral Head will be outside Acetabulum

Check the sex of the patient.

Ø Look at Soft Tissue Shadow under the Symphysis Pubis

Ø Male:

i. Look for Penis

ii. If see what appears to be upside down “wine glass” – Male Pelvis

iii. Angle under Symphysis Pubis – approximately 90 degree – male pelvis

Ø Female:

i. If see what appears to be “upside down margarita glass” – female pelvis

ii. Angle under Symphysis Pubis - 140°-150° - female pelvis.

6-8) Check Color and Shape of One Ilium, Pubis and Isheum to the other

Ø Shape- PFF

i. Paget’s Disease

ii. Fracture

iii. Fibrous Dysplasia

Ø Color

q Whiter

i. Paget’s

ii. Bastic Mets

q Darker

i. Lytic Mets

ii. MM

iii. Benign Bone Tumors

9) Compare Proximal Femur Head and Acetabulum to the other side for Alteration of Size and Color

Ø Two Conditions

I. DJD of the Hip

Loss of Superior Lateral joint space

Sclerosis of Femoral Head side and Acetabular Side

II. AVN of the Hip

Superior Lateral Joint Space is preserved.

Only get Sclerosis on Femoral Head Side.

ü NOTE: Superior Lateral Aspect of Hip joint is the weight bearing part of the joint. The best way to differentiate the two is by the thickness of the Sclerosis.

DJD – Thickness is similar on both sides of joint

AVN – Thickness is grossly different.

10) Compare Femoral Neck and Shaft to other side for Alteration of shape and Color

Ø Shape- PFF

i. Paget’s Disease

ii. Fracture

iii. Fibrous Dysplasia

Ø Color

q Whiter

i. Paget’s

ii. Bastic Mets

q Darker

i. Lytic Mets

ii. MM

iii. Benign Bone Tumors

Check Soft Tissue of Pelvic Inlet

Ø Look for:

i. Uterine Fibroids AKA “Mulberry Mass” Appearance: Round, White Density in center of Pelvic Inlet.

Most Common Benign Tumor of the Pelvic Inlet in WOMAN.

ii. Calcified Prostate: Round, White Density sitting on top of Symphysis Pubis.

iii. Ureter Stones

iv. Phlebolithes

Uterine Fibroid VS Calcified Prostate

Best way to differentiate the two:

Look at the Sex of Patient

Color of Uterine Fibroid – WHITE

Shape of Uterine Fibroid – WHITE

Shape of Calcified Prostate - Round

Ureter Stones VS Phlebolithes

Draw a straight line at the femoral head to femoral head.

If you see round, white densities above that line – Ureter Stones

If you see round, white densities below that line – Phlebolithes


Ø Paraglenoid Sulci

q          Only seen in women, but not seen in all women.

q          They form from superior gluteal artery getting pushed against bone in pregnant women.

Ø Lytic Mets VS Multiple Myeloma

q          Lytic Mets will see Holes grossly different in size

q          MM will see holes similar in size

Ø If you see bilateral pubis and bilateral isheal Fractures => Saddle Fracture.

Ø Prostusio Acetabuli

Ø Use Kohler’s Line to Dagnosis it -It is drawn along inner portion of pelvis, the femoral head should not cross that line.

Ø If Femoral head does cross that line that means positive Kohler’s Line = Protusio Acetabuli

Ø Common Conditions that cause this:

i. Paget’s

ii. Fibrous Dysplasia

iii. Trauma

iv. Severe DJD

v. Osteomalacia

ü Note: Bilateral Protusio Acetabuli is AKA Otto’s Pelvis. The M/C cause of Otto’s Pelvis is RA.

Slipped Capital Femoral Epiphysis

Ø Usually seen in overweight males.

Ø Use Klein’s Line to diagnosis => is drawn along superior aspect of the neck of femur. It should hit some portion of the femoral head to be normal. Positive Klein’s line = positive slipped femoral epiphysis.

Ø The M/C type I Salter- Harris Fracture (only seen in bones with open growth centers)

Ø Best view to diagnosis slipped capital femoral epiphysis is Frog Leg View.

Ø Clinically, typically seen between 10-16 years old overweight males.

Ø Painless, limp and have referred pain to groin and to knee.

Ø On exam: ↓ internal rotation and abduction of hip

Ø Most cases they leave it alone and let it heal.

Ø Healed SCFE in adults: all growth centers will be closed, but still have positive Klein’s line.

Types of Salter-Harris Fractures

I. Fracture through growth center and get sliding of Epiphysis over metaphysis.

II. Fracture through metaphysis and Growth center (M/C of all of them)

III. Fracture through Epiphysis and Growth Center

IV. Fracture Through everything

V. Compression of Growth Center – worst prognosis since it may cause shortened limb.

Legg Calve Perthes Disease

Ø AVN of hip in a child (4-9 years old)

Ø Takes 2 months for AVN to show up on the X-ray

Ø Cause is Trauma

Ø 4 Radiographic signs (may not see all of them)

i. Flattening of the Femoral Head

ii. Fragmentation of femoral head (“Crescent Sign”)

iii. Whitening of Femoral Head (“Snow Cap Sign”)

iv. Joint space will be wider

Ø Best imaging modality for AVN is MRI; if you cannot order MRI, order BONE SCAN

Ø Healed Legg Calve Perthes disease:

i. Flattening of femoral head

ii. No fragmentation of femoral head

iii. No whitening of femoral head

iv. Joint space will still be wider

Part IV: Mushroom shaped deformity

Presents with painless, limp, pain referred to groin and knee.

On exam-↓internal rotation and abduction of the hip

Part IV: Common outcome-early DJD

Extremity Films

Ø Office Motive: Pain or Dysfunction

Ø Read them from Proximal to Distal anatomically.

Ø Six Steps

1st check Periosteum

Check Cortex

Check Medulla

Check Joint Spaces

Check Growth Centers

Check Soft Tissues

1. First Check Peristeum

Ø Periosteal Reaction: New bone growth in response to cortical destruction (not normal)

Ø Two basic types of Periosteal reactions:

I. Linear AKA Parallel AKA Laminated

q          2 conditions come to mind

i. Trauma

ii. Infection

II. Spiculated AKA Sunburst AKA Radiating

q          Primary malignancy of bone such as a sarcoma

Linear Periosteal Reactions

Ø Only occur on long tubular bones

Ø You must see a thin white line dark line, cortex of bone

Ø To differentiate Trauma VS Infection

Ø Look for signs of Trauma

q          Radiolucent line to indicate fracture line

q          Bony callus (appears as cloudy, white density)

Ewing’s Sarcoma

Ø 10-25 years old

Ø Usually in Diaphysis of the bone

Ø In order to diagnose you must see the following 3 signs:

i. Multilaminated (Onion Skin Appearance) of a periosteal reaction

ii. Lytic areas (100% in the Medulla) surrounded by sclerosis

iii. Boney Expansion

If you donot see all three, then you do not have Ewing’s

ü NOTE: Lytic Mets, MM, Blastic Mets do not Affect the Cortex.

When you see periosteal reaction, then ask “is it Linear?”

If NO, then it is Speculated.


Ø Two basic types



Ø Congenital scoliosis is a result of congenital anomaly on the film (i.e. most likely a hemivertebra)

Ø If you cannot find a congenital anomaly then it is idiopathic.

Ø Structural – scoliosis does not change based on position.

Ø Functional – Scoliosis will change based on position.

Ø Name it by convexity of Curve.

Ø Measure Scoliotic Curve:

Cobb Method (Best Way!!!)


Ø Monitoring Scoliosis

q          < 20° adjust and monitor

q          20° to 40° refer out for BRACING

q          40° surgery

ü Note: For Part IV anything over 20° you do not treat – Refer out

Ø Children

X-ray them every 2-3 months to monitor curve

Always measure the larger curve if you see two curves on the film.

Will also name it based on large curve

Ø Complications of Scoliosis

q          Cardiopulmonary problems

q          Postural fatigue

q          May cause early DJD due to altered weight bearing

Ø Pattern for part IV

Pick condition you know it is = 1st answer

When picking 2nd answer, do the following:

i. 1st Look for AKA of condition

ii. 2nd Look for Radiographic sign associated with that condition

iii. 3rd if none of above is there – Pick Differential

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