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RADIOLOGY READING PROCEDURE

medicines

+ Font mai mare | - Font mai mic



RADIOLOGY READING PROCEDURE

Radiology Densities

  1. Gas is black.
  2. Fat is black.
  3. Muscle, water, soft tissue are grey.
  4. Bone and metal are white.



If you see something you don’t know what it is, ask 5 questions (CLASS)

  1. what is the color?
  2. what is the location?
  3. what is the age?
  4. what is the shape?
  5. what is the sex?

Part IV – Responsible for the most clinically significant thing.

DJD – only pick this diagnosis if there is nothing more clinically significant on the film.

6 Motive Steps (Do these on every film)

  1. Identify the view.
  2. “Office Motive” – why did the doctor take that film.
    1. Lateral cervical – routine scout film (screening film)
    2. Oblique cervical – view IVF’s
    3. Oblique lumbar – view pars and facets
    4. PA ulnar deviated film – look at scaphoid and lunate only
    5. Cervical flexion and extension – to check for

i. Abnormal motion and/or fusion (to check for stability/instability of ligaments)

ii. Contraindicated in all fractures except Clay Shoveler’s fracture

iii. Contraindicated in traumatic dislocations

iv. Contraindicated in infections and in malignancies

v. The only time you will see dislocated fact on the flexion film is when it is due to RA.

  1. Color motive – how does the film appear 5 color motives:
    1. Bone is white, soft tissue is gray, gas is dark or black = normal color motive
    2. Bone is white, soft tissue is white, the film is underpenetrated (underexposed) = terrible bone film or taken for soft tissue

i. 1st you check the bones

ii. If bones are fine, then check soft tissue.

    1. Bone is dark, Soft tissue is dark, the film is overpenetrated (overexposed) = terrible bone film or taken to see one area of the film.

i. ** Don’t worry about what you can’t see, only worry about what you can see.

ii. ** If you can’t see it, then you can’t read it, then you can’t diagnosis it.

    1. Bone is grey, soft tissue is grey, the film is osteopenic.

i. 1st look for a condition to explain the osteopenia

hyperparathyroidism

lytic mets

multiple myeloma

RA

AS

ii. If you can’t find a condition to explain the osteopenia then change your diagnosis to osteoporosis. To confirm this you must see pencil thin cortices going all the way around the vertebra.

    1. Bone is white, soft tissue is dark or black = color motive is bone film.

i. This is not the 1st film that the Dr. has taken – it is the 2nd/3rd film.

ii. If you see a bone film – the problem is in the bone.

  1. 1st impression – Is it normal or abnormal? Am I distracted on the film?
    1. If you are not distracted – 1st impression is normal.
    2. If you are distracted – 1st impression is abnormal. If 1st impression is abnormal then you go to 2nd impression (5th motive step)
  2. 2nd impression – Ask yourself , whatever distracted me, is it congenital, it is acquired, or are you not sure?
    1. If congenital, then once you have a congenital anomaly on the film you no longer worry about alterations of color from Paget’s, infections, or malignancies. You no longer worry about subtle fractures, subtle dislocations. The only time you will pick an acquired condition once you have a congenital anomaly on that film is if the acquired condition is obvious to override the congenital anamoly. **When in doubt, leave it out. When it’s there, it’s there.
  3. Check normal anatomy for age, sex, and deformity.
    1. Age – biggest differential Part IV – usually will be given age

Anterior, superior endplate – last portion of vertebra to ossify. If every single vertebra has this – person is under 20 yrs old.

Square vertebral body – person is 20-40 yrs old.

Signs of DJD on film – person is over 40 yrs old.

    1. Sex – not important in spine, more important in pelvis.
    2. Deformity – the bending or twisting of bones with the cortex still relatively intact

i. Deformity in spine – Paget’s and congenital anomaly

ii. Deformity in extremity – Paget’s and fibrous dysplasia

MOTIVE IS MY FRIEND. MOTIVE WILL GET ME A LICENSE.

LATERAL CERVICAL VIEW, FLEXION AND EXTENSION VIEWS IN CERVICALS

Office motive of lateral cervical – routine scout film

Office motive of flexion and extension views – check for abnormal motion and/or fusion

(to check for stability/instability of ligaments)

Mainly interested in transverse ligament of atlas and posterior restraining ligaments.

Best view to diagnose occipitalization is cervical flexion view.

ADI space should not change from neutral lateral to cercial flextion to cervical extionsion.

Part IV- look at angle of back of mandible to determine view if jaw is cut off.

15 Steps

  1. Check ADI space.
  2. Check spinolaminar line of C1 in relation to C2.
  3. Come down front of bodies.
  4. Check base of dens.
  5. Approximate dens for height, alignment, and color.
  6. Check vertebral bodies for alteration of shape and alteration of color.
  7. Check disc spaces for alteration of size and alteration of color.
  8. Check arch of atlas.
  9. Check space between CO/C1 and C1/C2.
  10. Check pedicle of C2.
  11. Come down back of bodies.
  12. Check facets.
  13. Check spinolaminar lines.
  14. Check spinouses.
  15. Check soft tissue in front of spine.

DETAIL OF 15 STEPS

  1. Check ADI space
    1. Can you see ADI space?

i. Yes – rules out agenesis of dens

Is it normal or abnormal in width (no more than 3 mm in adult or 5 mm in child)

a.       Abnormal – increased ADI. Conditions that can cause increase ADI

i. Down’s Syndrome (not an x-ray diagnosis; 20-30% do not have transverse ligament of atlas)

ii. Trauma (inflammation)

iii. RA (inflammation)

iv. AS (inflammation)

v. Psoriatic Arthritis (inflammation)

vi. Reiter’s Syndrome (inflammation)

**Inflammation – Loss of function

Ligaments function to hold two bones together. Any condition that causes inflammation could cause increased ADI.

The ADI is normally a thin, black line. If the width of the ADI space is similar to the width of the anterior tubercle then you have an increased ADI.

  1. Check spinolaminar line of C1 in relation to C2 to see if atlas is in place or displaced. To check it – draw straight vertical line along back of C2 body and roll line posterior until you hit midpoint of spinolaminar line of C2. That vertical line should hit some portion of spinolaminar line of C1 for atlas to be in place.
    1. If atlas is anterior:

i. Increased ADI

ii. Fractured dens

iii. Unstable os odontoideum

iv. Agenesis of dens

    1. If atlas is posterior:

i. Fractured dens

ii. Unstable os odontoideum

iii. Agenesis of dens

  1. Come down front of bodies checking for 4 things:
    1. Look for lipping spurring of DJD or infection, but don’t rule them in or rule them out until you check disc spaces.
    2. Look for hyperostosis (AKA candlewax drippings, AKA anterior spinal bridging) of 4 or more segments to indicate DISH (they do not have to be continuous).

DISH – calcification of ALL; preserves disc spaces; never involves the facets in terms of fusion; non-inflammatory; 30% have diabetes mellitus. May not want to adjust Gonstead since they go through disc plane line and not through facet plane line

    1. Look for syndesmophytes – inflammatory spurs, calcification of ALL or annular fibers of disc. There are two types:

i. Marginal syndesmophytes – seen with AS

Look at anterior aspect of disc space – if calcification disappears when you cover up anterior aspect of disc – it is marginal syndesmophytes of AS. Confirm this by seeing eggshell calcification of disc (this is not always there).

ii. Non-marginal syndesmophytes – Psoriatic arthritis or Reiter’s (can only differentiate these in the spine by case history – Psoriatic – silver scales, pitted nails; Reiter’s – can’t see, can’t pee, can’t dance with me)

If you come down the front of the bodies and you see what looks like DISH, but the facets are fused – it is not DISH, it is Psoriatic or Reiter’s and you are looking at non-marginal syndesmophytes.

    1. Look for avulsion fractures or compression fractures

i. MC avulsion fracture in cervical spine – tear drop fracture = avulsion of the anterior, inferior aspect of vertebral body (MC area os C2) mechanism of injury is hyperextension.

ii. Compression fracture – loss of anterior body height 25% or more. If see this, think MOPIT

M – malignancies

O – osteoporosis

P – Paget’s

I – infection

T – trauma

  1. Check base of dens for radiolucent line. Base of dens is located just above the ring of sclerosis of C2 (TP of C2). If see a radiolucent line, there could be 4 reasons:
    1. Fractured dens
    2. Os odontoideum
    3. Agenesis of dens
    4. Mach line (shadow on film) – rule the other 3 out before you pick this.
  1. Approximate dens for height, alignment, and color
    1. Height – similar to height of C2 body. Check to see if the majority of the dens is below the occiput

i. If yes – rules out basilar invagination

ii. If no – diagnosis is basilar invagination. MC causes:

Paget’s

Fibrous Dysplasia

Trauma

Two lines that can be used:

Chamberlain’s line – from back of hard palate to posterior aspect of foramen magnum. Dens should be no more then 7mm above that line.

McGregor’s line – from back of hard palate to base of occiput. Dens should be no more than 8mm in male or 10mm in female above that line.

    1. Alignment – Come to the front and back of body of C2 and see if dens is in place or displaced.

i. If displaced:

fractured dens

unstable os odontoideum (AKA ununited dens, nonunion of dens)

**os odontoideums are usually not diagnosed off a lateral cervical film (use A-P open mouth).

Part IV – may ask you to do it off lateral film- if see

tomogram (“blurry film”) with radiographic signs of os odontoideum – radiolucency that is smooth with cortical margins around the two fragments.

See obvious radiographic findings of os odontoideum – big, thick radiolucency that is smooth with obvious cortical thickening around the two fragments.

***Anytime you have a bone displaced from itself, you will assume it to be fractured until proven otherwise:

office motive may prove otherwise – it is not a film that the Dr. would have taken if that bone was suspected of being fractured.

Another thing that may prove otherwise is if you have the obvious radiographic signs of nonunion (see above).

    1. Color – compare color of where dens would be to the anterior, inferior aspect of body of C2. Is it obviously whiter?

i. If yes – rules out agenesis of dens

SN – Anything that is penetrated on x-ray appears darker. Anything that is not penetrated on x-ray appears whiter.

  1. Check vertebral bodies for alteration of shape and alteration of color.
    1. Shape – “PFC”

i. Paget’s

ii. Fractures

iii. Congenital anomalies

    1. Color – When you see color change in vertebra – determine if the color change is a technical color change or a pathological change?

i. Technical – bones change one way and the soft tissue follows

ii. Pathological – bones change one way but the soft tissue does not follow

Whiter – Blastic mets or Paget’s

If you see ivory white vertebra in someone under 30 yrs old then you are looking at Hodgkin’s

MC cause of Ivory White Vertebra = blastic mets

Darker – Lytic mets or multiple myeloma

**Anytime you have white density in bone other than proximal femur heads or the carpal bones you will assume it to be blastic mets until proven otherwise. 5 way to prove otherwise:

i. History (age of pt)

ii. Lab work – if alk. phos. is normal it is not blastic mets

iii. Biopsy the tissue

iv. Bone scan

v. If you have radiographic signs of cortical thickening, enlargement, or deformity of bone to indicate Paget’s disease.

By the time the vertebra is ivory white due to Paget’s it will be obviously larger.

Earliest sign of Paget’s on x-ray is the picture frame vertebra appearance.

When checking for enlargement, not only check for vertical enlargement, also check for horizontal enlargement.

SN – Blastic mets affect medullary bone (needs blood) while Paget’s affects cortical bone.

  1. Check disc spaces for alteration of size and alteration of color. Two biggest conditions are:
    1. DJD (AKA discogenic spondylosis)

i. Decreased joint space

ii. Subcondral sclerosis (AKA eburnation)

iii. Lipping and spurring (if severe)

    1. Infection (#1 organism – staph aureus)

i. Decreased joint space

ii. Joint space may turn whiter

iii. **destruction of bone on both sides of the joint. (won’t see white line of endplate). The only condition that gets into joint space and destroys bone on both sides of joint is an infection.

SN – 2 MC causes of vacuum phenomenon:

DJD

Trauma

  1. Check posterior arch of atlas to see if it is present or absent.

a. If missing, there can be 3 reasons:

i. Cut away due to surgery

ii. Eaten away due to malignancy – will see “teeth marks”

iii. Congenitally absent (AKA Agenesis of posterior arch of atlas)

Before you put down agenesis of posterior arch of atlas, check to see if it is fused to occiput in occipitalization.

To differentiate surgery from congenitally absent – look for sign of surgery on the x-ray – staples and wires.

    1. If posterior arch is present, check for vertical radiolucencies of:

i. Fracture

jagged radiolucency

usually no cortical margins around two fragments

**there will be displacement

ii. Non-union

radiolucency is smooth

usually will see cortical margins around two fragments

**no displacement

SN – horizontal radiolucencies through posterior arch of atlas – mach lines

  1. Check space between CO/C1 and C1/C2 – Is it similar or is it grossly unequal? If grossly unequal – there is a problem. Go back through previous steps, you missed something.
  1. Check pedicle of C2 for vertical radiolucency.

If you see one – fracture (always)

Hangman’s fracture – mechanism of injury = hyperextension

Part IV – classified as type IV spondylolistesis

#1 differential for fracture = non-union. Non-unions only occure inareas of growth centers (no growth center in pedicle)

Typical vertebra – 3 primary centers of ossification

- vertebral body

- 1 in each lamina

5 secondary centers of ossification

- 1 in each endplate

- 1 in each TP

- 1 in spinous

  1. Come down the back of the bodies—check for 3 things:
    1. Look at overall curve

i. If straight curve (military neck)-alordotic

ii. Reversal of normal curve-kyphotic

    1. Look for decrease of posterior body height, posterior body destruction to indicate malignancy—this is only a diagnosis if no other sign of infection or trauma are on the film

i. M – malignancy-↓ of anterior and posterior body height

ii. O – osteoporosis-loss of anterior body height, but posterior body height is preserved (giving wedge shaped vertebra)

iii. P – Paget’s-see cortical thickening, enlargement, or deformity of bone

iv. I – Infection-see destruction of bone on both sides of joint

v. T – trauma-look for V-shaped defects, boney fragments, boney debrie

**Any one radiographic sign in and of itself is useless. Add up all signs and the one with the most wins.

Part IV – compression fracture due to trauma – called compression fracture. If it is due to any other cause, it is called pathological compression fracture.

    1. Slipping and sliding of a subluxation or dislocation (antero or retrolistisis)

i. Subluxation – up to 10% slippage of one vertebra upon the other with the facts still in line. Use George’s line-drawn along the back of vertebral bodies. Start at the bottom and come up. Name by looking and vertebra above and comparing it to vertebra below.

ii. Dislocation – 25% or more slippage of one vertebra upon the other with the facets overriding or perching

***immediate referral for surgery (call 911 and get them there by

ambulance)

Name by looking at vertebra above and comparing to the one

below. (ie dislocation of 5 on 6)

When you have a dislocation of a vertebra, it has occurred at the

facets.

iii. Between 10-25% slippage, look for fanning of spinouses – if see fanning you have a dislocation. If no fanning, then it is a subluxation.

If you see fanning of spinouses at any point in time – dealing with a dislocation. Need to tear 4 ligaments to get this

-supraspinous ligament

-interspinous ligament

-ligamentum flavum

-capsular ligament

Sometimes the facet dislocation could reduce, but the fanning of the spinouses with always remain.

  1. Check facets. Only 3 things can happen to the facets:
    1. Dislocated

i. RA

ii. Trauma

To differentiate, look for sign of trauma on film.

    1. Destroyed

i. RA

ii. OA

To differentiate, if see “teeth marks” in facet joints = rat bite erosions of RA

    1. Fused

i. RA

ii. AS



To differentiate, look down front of bodies if see marginal syndesmophytes-AS, if don’t see marginal syndesmophytes-RA

If none of the 3 above have happened, then they are normal.

  1. Check spinolaminar lines. Looking for one that is missing = spina bifida

If see is at C1, aka spondyloshisis

Spina bifida in cervical spine – MC at C1, C6, C7. MC cause - ↓ in folic acid

  1. Check spinouses – check if they are present or absent.
    1. If absent – 3 reasons:

i. Cut away due to surgery

ii. Eaten away due to malignancy

iii. Congenitally absent.

(same differentiation as with step 8)

Surgical removal of spinous = laminectomy

Part IV - If see congenital absence of one spinous, it is congenital

absence. If see it in 2 spinouses, still congential absence. If see it

in 3 or more spinouses, change answer to surgery.

    1. If present – check for fractures

i. Clay Shoveler’s fracture – MC seen at C6, C7, T1. Mechanism of injury is hyperflexion.

Part IV – 50% of the time when you have a ponticulus posticus there is also a Clay Shoveler’s fracture.

  1. Check soft tissue in front of spine.
    1. Retropharyngeal – C4 no more than 7mm
    2. Retrolaryngeal – C5 no more than 14 mm
    3. Retrotracheal – C6 no more than 22mm in adult or 14mm in child

MC causes of soft tissue swelling:

trauma

infection

malignancies

Part IV – If the width of the soft tissue is wider than the width of the vertebral bodies then have soft tissue swelling. In order for you to diagnose infection on lat. cervical film, and soft tissue can be visualized, you must see soft tissue swelling.

MISCELLANEOUS INFO

If see IVF on lateral cervical film, could be 3 reasons:

fusion of facets

excessive rotation of facets

neurofibroma

Congenital vs. Acquired Blocked Vertebra (follow steps in order)

Always make the call from the front of the body (anterior portion of body). If see wasp-waist deformity = congenital block.

If cannot make call form the front of the bodies, go to the disc space. Draw straight vertical line along anterior aspect of disc space – Do I see bulging in front of that line ?

a.       Yes – acquired block

b.      No – congenital block

If still unsure – check facets. Go to where two facets are fused – ask How many spinouses do I see? How many spinolaminar lines do I see? 1 spinous, 1 spinolaminar line = congenital

2 spinouses, 2 spinolaminar line = acquired

If see ↓ of body height on A-P film, most likely posterior body height is

decreased.

Horizontal radiolucencies going through vertebra are moch lines.

Vertical radiolucencies going through vertebra are fractures.

Part IV – Mach line called – hemispherical spondylosclerosis—usually indicates discogenic spondylosis but more importantly uncinate arthrosis.

If see multiple congenital blocked vertebra, change diagnosis to Klippel-Feil Syndrome.

Two conditions that “eat” bone

malignancies (lytic mets and multiple myeloma)

infection

To differentiate – look to nearest joint, if have destruction on both sides of joint = infection (confirm by looking for soft tissue swelling). If have destruction on only one side of joint = malignancy

Fusion due to surgery = arthrodesis

Fusion due to pathology = ankalosis

AS – starts in SI joints, then moves to thoracolumbar area, then goes up and down from there.

A-P OPEN MOUTH

Office motive – view dens and arch of atlas

12 steps

1. Check to see if dens is present.

2. Check the structures creating mach lines.

3. Check base of dens for radiolucent line.

4. Outline dens to see if it is in place or displaced.

5. Check paraodontoid interspaces.

6. Check lateral masses of C1 with respect to body of C2 for overhang.

7. Check lateral masses for alteration of shape and alteration of color.

8. Check TP’s for alteration of shape.

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

10. Check disc space between C2 and C3 for alteration of size and alteration of color.

11. Check arches of atlas, spinous of C2 and C3 for vertical radiolucencies. Check spinous of C2 and C3 for horizontal radiolucencies.

12. Check soft tissue in and around the jaw.

DETAIL OF 12 STEPS

  1. Check to see if dens is present.

a.       If present, rules out agenesis of dens.

b.      If not present, agenesis of dens.

  1. Check structures creating mach lines (3 structures).
    1. Arches of atlas

i. Smiling arch = posterior arch

ii. Frowning arch = anterior arch

    1. Occiput
    2. Teeth – vertical radiolucency through dens is mach line created by the two incisor teeth.

**Horizontal raciolucency = fracture.

  1. Check base of dens for radiolucent line
    1. If see radiolucent line – ask “is it thin or is it thick?”

i. Thin = fracture

ii. Thick = os odontoideum

Base of dens – come up facet of C2 to where it ends and just draw horizontal line straight across..

  1. Outline dens to see if it is in place or displaced.
    1. If displaced – fractured dens

Part IV – called titled or leaning odontoid

Be careful that it is not just subluxated – superior on one side.

3 types of dens fractures:

Type I – thin radiolucent line above base of dens (stable fractures)

Type II – thin radiolucent line through base of dens (MC dens fracture)

Type III – thin radiolucent line below base of dens (stable fractures)

Type II – the most unstable dens fracture – most severe.

**Never adjust, call 911 (for any of the types of fractures).

  1. Check paraodontoid interspaces to see if they are unequal or enlarged.
    1. If they are, you are suspecting a possible Jefferson’s Bursting Fracture (confirm with step 6)
  1. Check lateral masses of C1 with respect to body of C2 for overhang—take vertical line up lateral aspect of body of C2, does lateral mass of C1 cross that line? (If it touches the line—that is fine)
    1. If yes = overhang. 3 scenarios

i. Overhang on one side, but lateral mass on otherside shifted in same amount – normal – just subluxation (atlas laterality)

ii. Overhang on one side, but lateral mass on otherside did not shift in equal amount = Jefferson’s Bursting Fracture (JBF)

iii. Overhang on both sides = Jefferson’s Bursting Fracture. This is the MC way a JBF will present. Called bilateral lateral mass.

    1. If no = Not overhang.
  1. Check lateral masses of C1 for alteration of shape and alteration of color.
    1. Alteration of shape

i. P – Paget’s

ii. F – Fractures

iii. C – Congenital anomaly

    1. Alteration of color

i. Whiter – blastic mets of Paget’s

ii. Darker – lytic mets or multiple myeloma

  1. Check TP’s of atlas for alteration of shape. Biggest thing you will see affecting the shape = congenital anamoly
    1. Epitransverse process – goes from superior aspect of transverse of C1 toward occiput.
    2. Paracondylar or paramastoid process – goes from occiput down to superior aspect of TP

If pseudoarticulation is closer to occiput = epitransverse

If pseudoarticulation is closer to TP = paracondylar or paramastoid

  1. Check body of C2 & C3 for alteration of shape and alteration of color.
    1. Alteration of Shape = PFC (Paget’s, Fractures, Congenital Anomalies)
    2. Alteration of Color = Whiter – Blastic mets or Pagets

Darker – lytic mets or Multiple myeloma

**Never put down lytic mets/blastic mets on AP Open Mouth unless you are willing to bet your life that it is there – usually diagnosed on lateral film.

  1. Check disc space between C2 & C3 for alteration of size and alteration of color. Concerned with two conditions:
    1. DJD - ↓ joint space, subcondral sclerosis, lipping and spurring
    2. Infection - ↓ joint space, joint space may turn whiter, *destruction of gone on both sides of the joint.
  1. Check arches of atlas, spinous of C2 and C3 for vertical radiolucencies. If see one = spina bifida

Check spinous of C2 and C3 for horizontal radiolucencies. If see one – spinous fracture (Clay Shoveler’s fracture – more common @ C6, C7, T1)

  1. Check soft tissue in and around the jaw. Biggest thing you will see – lymph node calcification. If see multiple calcified lymph nodes – chronic infection.

MISCELLANEOUS INFO

Os terminale (ossiculum terminale) – big, thick radiolucency above the base of dens

Diamond shape tip to the dens = normal growth center

Burst fracture – vertical radiolucency through bone w/break in cortex at both ends. Always have displacement.

A-P LOWER CERVICAL

Motive – routine scout film.

Never put down spina bifida of C4 unless you are willing to bet your life that it is present on that film.

7 Steps

1. Find last set of TP’s that point upwards = T1

2. Check C7 TP’s

3. Check vertebral bodies for alteration of shape and alteration of color

4. Check disc spaces and uncinates for alteration of size and alteration of color

5. Check spinouses for vertical radiolucency of spina bifida. Check spinouses for horizontal radiolucency of fracture

6. Check tracheal air shadow for deviation

7. Check soft tissue on both sides of spine

NEVER MAKE A LUNG PATHOLOGY DIAGNOSIS ON ANY OTHER FILM OTHER THAN CHEST FILM.

DETAIL OF 7 STEPS

1. Find last set of TP’s that point upwards = T1. Purpose is to orientate yourself in the spine.

2. Check C7 TP’s. Looking for 3 things:

  1. Cervical ribs - If you see a rib articulating with C7 TP = cervical rib. (may not look like a rib – if see two bones articulating at TP – most likely cervical ribs)
  2. Elongated, hypertrophic TP’s of C7 - Elongated hypertrophic TP’s of C7 – come to lateral aspect of TP of T1, draw vertical line upward – Does C7 TP cross that line?

Yes – elongated hypertrophic TP of C7

  1. TP tractures – look for jagged radiolucency, usually no cortical margins around two fragments, **displacement.

3. Check vertebral bodies for alteration of shape and alteration of color

Shape – PFC (Paget’s, Fractures, Congenital Anomalies)

Color – Whiter – blastic mets or Paget’s

Darker – lytic mets or multiple myeloma

4. Check disc spaces and uncinates for alteration of size and alteration of color.

- DJD - ↓ joint space, subcondral sclerosis, lipping and spurring

- Infection - ↓ joint space, disc may be whiter, *destruction of bone on both sides of joint.

Uncinates – if uncinate is flattened and going lateral = blunting of uncinates which is indicative of uncinate arthrosis AKA uncinate hypertrophy. Normal – should be vertical.

The MC cause of IVF encroachment is uncinate arthrosis – do not want to adjust segment with rotation.

5. Check spinouses for vertical radiolucencies of spina bifida and horizontal radiolucencies of a fracture. If see vertebra with what appears to be 2 spinouses = double spinous sign indicative of spinous fracture (AKA Clay Shoveler’s fracture)

6. Check tracheal air shadow for deviation. “Atelectasis sucks” – sucks the trachea to side of collapse.

7. Check soft tissue on both sides of spine. Looking for two big things:

- carotid artery calcification

- lymph node calcification

Two ways to differentiate the two:

If you see calcification in shape of V = carotid artery calcification

If you see one round white density it is either lymph node calcification or carotid artery calcification. They must show you more than one round white density. If you can line up those round white densities in a straight vertical line, then it is carotid artery calcification. If you can’t, then lymph node calcification.

CERVICAL OBLIQUES

Office motive – to view IVF’s. Do not look at anything else, except IVF’s.

Never put down occipitalization on an oblique film.

*On anterior obliques – marker always goes behind spine. On posterior obliques – marker always goes in front of the spine.

In the cervicals, anterior obliques – same side IVF

posterior obliques – opposite side IVF

The 1st IVF you see is between C2 & C3.

Cervicals – nerve root involvement, always 2nd number.

ie – C2/C3 IVF encroachment would affect C3 nerve root.

C7/T1 IVF encroachment would affect C8 nerve root.

Anatomy of IVF –

Anterior border – formed by bodies and uncinates

Superior and inferior border – formed by pedicle

Posterior border – formed by facets

Start at top and come down, and compare size and shape of one IVF to the other. Two things can happen to IVF:

If IVF gets smaller, think IVF encroachment, but need to confirm by looking for hourglass IVF’s (look for pinching in the middle)

If IVF gets bigger (3 reasons why)

a.       Lytic mets of pedicle (rare in cervical spine)

b.      Agenesis of pedicle

c.       Neurofibroma

To differentiate agenesis vs. neuofibroma – draw straight vertical line along back of vertebral bodies, ask Do you see scalloping out of back of bodies?

Yes – neuorfibroma

The useless radiographic sign for neurofibroma = dumbbell shaped IVF (Don’t look for it.)

Neurofibroma – tumor of nerve root; they are very expansile. Treatment-surgically remove tumor. Can get more than one – neurofibromatosis AKA VonRecklinghausen disease. Also get skin lesion – café au lait spots w/smooth borders (“coast of California” appearance).

SN – Fibrous dysplasia also get café au lait spots w/jagged borders (“coast of Maine” appearance.

A-P THORACIC

Office motive – routine scout film

Will be read identically to A-P lumbar film in terms of the square blockhead vertebra system.

**Any condition that increases blood supply to bone will turn bone darker. Any condition that cuts off blood supply to bone will turn bone whiter. (AVN of scaphoid – turns whiter). Any condition that is inflammatory will turn bone darker since blood supply is increased.

LATERAL THORACIC

Office motive – routine scout film.

4 steps

1. Come down the front of the bodies looking for 4 things.

2. Check vertebral bodies for alteration of shape and alteration of color.

3. Check disc spaces for alteration of size and alteration of color.

4. Come down back of bodies looking for two things.

DETAIL OF 4 STEPS

1. Come down the front of the bodies looking for 4 things:

- lipping and spurring of DJD or infection, but don’t rule then in or rule them out until you check disc spaces.

- candle-wax dripping, hyperostosis, anterior spinal bridging of DISH (4 or more segments)

- marginal syndesmophytes of AS

- avulsion fractures or compression fractures.

2. Check vertebral bodies for alteration of shape and alteration of color.

- Shape – PFC (Paget’s, fractures, congenital anomalies)

- Color – Whiter – blastic mets or Paget’s

Darker – lytic mets and multiple myeloma

3. Check disc spaces for alteration of size and alteration of color.

- DJD - ↓ joint space, subcondral sclerosis, lipping and spurring

- Infection - ↓ joint space, joint may be whiter, destruction of bone on both sides of joint.

4. Come down back of bodies looking for two things:

- look at overall curve

- look for decrease of posterior height, posterior body destruction to indicate malignancy. Malignancy is only a diagnosis if there are no other signs of infection or trauma.

MISCELLANEOUS INFO

Multiple myeloma – sometimes it causes ↓ of posterior body height of multiple vertebra in a row. **Thus check posterior body height of 2 or 3 segments above and below.

Slight loss of anterior body height up to 15%, 3 conditions come to mind—

mild compression fractures

infection

Scheuermann’s Disease

To differentiate:

with mild compression fractures – do not cause multiple end plate irregularities

with infection, destruction from joint space to joint space will be grossly unequal. (look at overall pattern of every joint space affected)

with Scheuermann’s Disease, destruction from joint space to joint space with be relatively equal. (look at overall pattern of every joint space affected)

Radiographic signs of Scheuermann’s Disease:

Slight loss of anterior body height of one or more vertebra

Multiple end plate irregularities of 3 or more continuous vertebra

Destruction from joint space to joint space will be relatively equal

If severe enough, you will get an increase in thoracic kyphosis.

Most likely outcome of this condition if left untreated

early DJD

postural deformity

Scheuermann’s Disease is usually seen between 10-16 years old. It is an avascular necrosis of secondary growth centers, specifically endplates.

Major cause of all AVN’s in the body = trauma

If any AVN in the body goes untreated it will lead to early DJD.

Best imaging modality for any AVN in the body is an MRI. (Bone scan – next best answer)

Part IV – they present with mid-dorsal pain and may have rounding of the shoulders. Child was lifting weights and now has mid-back pain.

adjust segments involved (keep them moving)

get them into thoracolumbar brace – takes pressure off anterior aspect of the bodies and prevents ↑ in thoracic kyphosis.

Schmorl’s Node – if see one it is a Schmorl’s node; if see two still Schmorl’s node (if same region of spine); if see three or more – change diagnosis to Scheuermann’s Disease.

Persistent Notocord AKA Notocordal remnant AKA nuclear impression – appears on A-P film as a “Cupid’s bow” deformity.

Schmorl’s nodes usually occur on anterior ½ of vertebra, can occur on superior or inferior aspect. Cause is trauma. Therefore borders of node are irregular.

Nuclear impressions usually occur on posterior ½ of vertebra. Usually on inferior aspect of vertebra. Borders of nuclear impression are nice and smooth.

Cannot see Schmorl’s nodes on A-P film.

If see giant Schmorl’s nodes (3 or more) in lumbar spine, condition you are looking at is Scheuermann’s disease.

LATERAL LUMBAR

Office motive – routine scout film

8 steps

1. Come down front of bodies checking for 4 things.

2. Check vertebral bodies for alteration of shape and alteration of color.

3. Check disc spaces for alteration of size and alteration of color.

4. Come down back of bodies looking for 3 things.

5. Check pedicles

6. Check pars

7. Check spinouses

8. Check soft tissue in front of spine

DETAIL OF 8 STEPS

1. Come down the front of the bodies checking for 4 things:

- lipping and spurring of DJD or Infection but don’t rule them in or rule them out until you check disc spaces.

- hyperostosis, candle-wax drippings, anterior spinal bridging of DISH (4 or more segments)

- marginal syndesmophytes of AS

- avulsion fractures or compression fractures

2. Check vertebral bodies for alteration of shape or alteration of color.

- Shape – PFC (Paget’s, fractures, congenital anomalies)

- Color – Whiter – blastic mets or Paget’s

Darker – lytic mets and multiple myeloma

3. Check disc spaces for alteration of size and alteration of color.

- DJD - ↓ joint space, subcondral sclerosis, lipping and spurring

- Infection - ↓ joint space, joint may be whiter, destruction of bone on both sides of joint.

4. Come down back of bodies looking for 3 things:

- overall curve (normal = lordotic)

- ↓ posterior body height, posterior body destruction to indicate malignancy, but this is only a diagnosis if there is no other signs of trauma or infection on that film.

- slipping and sliding of a subluxation (antero or retrolistesis) or spondylo

5. Check pedicles. Biggest thing will be pedicle fractures. If see vertical radiolucency – pedicle fracture.

6. Check pars. Biggest thing will be pars fractures. Trick to find it on a lateral film – go to the base of pedicle where it meets facet, draw 45° line – that is the pars. Ask yourself, Do I see radiolucent line there?

- yes – pars fracture

- no – normal

7. Check spinouses (on lateral lumbar they are usually overpenetrated – can’t see them)

If can see them – see one @ L1, and one at L3, nothing at L2-missing spinous:

- cut away due to surgery

- eaten away due to malignancy

- congenitally absent

Usually in lumbar spine you will not see obvious signs of surgery – need to look for another sign:

If see missing spinous with myelographic remnants – most likely reason is due to surgery (laminectomy).

8. Check soft tissue in front of spine.

**Abdominal Aorta – check from L2 to L4. It should be no more than 3.8cm; if greater then 3.8 cm = aneurysm

Part IV – normal width is ½ - ¾ the width of a lumbar vertebra. If the width of abdominal aorta is wider than the width of lumbar vertebra – aneurysm. Two radiographic sign used to describe calcification:

curvy linear calcification

half moon shape

MISCELLANEOUS INFO

AKA’s for flat vertebra:

vertebra planae

pancake vertebra

coin on edge sign

wrinkled vertebra sign

Differentiate limbus bone from avulsion fracture:

Limbus bone – radiographic signs

Radioluency is usually smooth

Usually there are cortical margins around the two fragments

*NO DISPLACEMENT

Avulsion fracture

Radiolucency is usually jagged

Usually there are no cortical margins around two fragments

*There will be displacement

When you come down the front of the bodies and see a boney fragments first assume it to be a limbus bone.

To change answer to avulsion must see displacement.

If you are unsure about displacement or not keep answer as limbus bone.

To check for displacement draw a straight vertical line along anterior body, does boney fragment fall within lin?

a.       Yes – limbus bone

b.      NO – Avulsion fracture

For every single segment that is affected by AS the marginal syndesmophytes must be bilateral and symmetrical.

SPONDYLO

5 Types

Type I – Dysplastic

Type II – Isthmic AKA spondylolytic spondylolisthesis

Type III – Degenerative AKA nonspondylolytic spondylolisthesis

Type IV – Traumatic

Type V – Pathological

Type I – Congential anamoly causing anterior slippage

Type II – Pars fracture causing anterior slippage

Type III – Usually DJD of the facets causing the anterior slippage

Type IV – Usually pedicle fracture causing anterior slippage Ex. Hangmans fracture in cervicals

Type V – Usually some kind of pathology (lytic mets or multiple Myeloma, Pagets) that cause compression of the vertebra resulting in anterior slippage.

When you see a vertebra slip anterior first try to explain why it went anterior (Type I – V spondylo’s) if you can’t explain then it is called anteriolithesis.

The way a spondylo appears on AP film is as a inverted Napolean hat sign. AKA “the bowl line of brailsford” AKA Gendarme cap sign (means man of arms)

If you see inverted Napolean hat sign you have atleast Grade III or more spondylo

Only way you will see lamina on AP film is if the vertebra has slipped anterior.

Person could present with no symptoms or bilateral leg pain.

“Inverted Napolean hat sign”

Meyerding Grading system

Ferguson’s sacral base line and ulmans line

Take segment below and divide it into quarters.

5 grades:

Grade 1 – 1-25% slippage

Grade 2 – 26-50% slippage

Grade 3 – 51-75% slippage

Grade 4 – 76-100% slippage

Grade 5 - > 100% slippage

If the L5 vertebra has slipped > 100% and has dropped down in front of the sacrum = spondyloptosis

If right on the border between two grades – go with the lower number.

If you have spondylo with spurring on sacrum – it is called the buttressing phenomenon (Innate is trying to stabilize)

LUMBAR OBLIQUES

Office motive – To view pars and facets

Anterior obliques - Marker behind spine

- See opposite pars (Scotty dog)

Posterior obliques - Maker in front of spine

- See same side pars (Scotty dogs)

Anatomy of Scotty Dog:

Nose – Ipsilateral TP

Back leg – Opposite inferior articular facet

Eye – Pedicle

Ear – Superior Articular facet

Tail – Opposite TP

Front leg – inferior articular facet

Neck – Pars

Body – Lamina

If Scotty dog is wearing black collar it is called collar sign indictive of pars fracture.

Biggest thing you will see affecting pars = pars fracture

The only thing you can can diagnosis on oblique film is spondylolysis (cannot see anterior slippage) so can’t say spondylolisthesis

Biggest thing you will see affecting facets = facet imberication

McNabbs Line – Drawn along inferior aspect of vertebral body. (Always go to highest line) The superior articular facet of the vertebra below should not cross that line. If it does – indicative of facet imberication.

AP LUMBOPELVIC

Office Motive – Routine Scout film

Square blockhead vertebra system:

Square block – body

Everyone’s head needs eyes – pedicles

Face needs nose – spinus

Head needs ears – TPs

Square blockhead

Vertical striations in one vertebra = hemangioma

½ vertebra = hemivertebra

Butterfly vertebra

Can turn WHITER – blastic mets or Pagets

Can turn DARKER – lytic mets or multiple Myeloma

Crushed blockhead – malignancy only a diagnosis if no other signs of infection or trauma on film

Eyes (pedicle)

Missing pedicle = lytic mets of pedicle or agenesis of pedicle AKA Owl winking sign

When you see a missing pedicle First assume it to be lytic mets.

a.       For you to change your answer to agenesis look at opposite pedicle.

b.      Ask “Is the opposite pedicle more sclerotic than the one above and/or the one below?

c.       Yes – agenesis of pedicle

d.      No – Lytic mets

There is a condition that causes a decrease in posterior body height, but spares the pedicles = multiple Myeloma

Called multiple Myeloma pedicle

It is a plasma cell leukemia found in bone marrow (medulla)

Very little plasma cells in the pedicles

Multiple Myeloma appears cold on BONE SCAN

5 Lab findings with multiple Myeloma

a.       IgG M-Spike

b.      Bence Jones protein uria

c.       Reversed A/B ratio

d.      Normocytic, normochromic anemia

e.       Rouleaux formation (stack of coins appearance)

Nose (spinous)

Is the nose present or absent?

If absent, 3 reasons why



a.       Cut away due to surgery

b.      Eaten away due to malignancy

c.       Congenitally absent

If Present, check for vertical radiolucencies of spina bifida.

a.       In lumbar – MC at L5/S1 area

Ears (TPs)

Biggest thing you will see is fractured TPs vs. non-union of TPs

Fracture

a.       Jagged radiolucency

b.      Usually no cortical margins around two fragments

c.       *DISPLACEMENT

Non-union

a.       Radiolucency usually smooth

b.      Usually have cortical margins around fragments

c.       * NO DISPLACEMENT

The only time you will put down TP fracture without displacement is if you see a boney callous. (Appears like a cloudy white density around bones)

Both can be bilateral

AP LUMBOPELVIC VIEW

13 Steps

1. Start off with lower 1/3 of SI joints.

2. Compare the color and shape of one ilium to the other.

3. Check for Riser’s sign.

4. Go to the top of iliac crest, draw line across and it should bisect L4/L5 disc space.

5. Count up the spine until you find the last set of ribs that point down = T12.

6. Count down the spine checking for a lumbosacral transitional segment.

7. Check sacrum for alteration of shape, alteration of color, and vertical radiolucencies.

8. Check L5/S1 facets for tropism.

9. Perform the square blockhead system all the way up the cpine.

10. Check the soft tissue on both sides of spine from L2-L4.

11. Check the soft tissue opposite the L2 vertebra bilaterally for renal artery

calcifications and renal artery aneurysms.

12. Check the soft tissue form the 12th rib down to iliac crest bilaterally. Look for gall

stones, kidney stones, and staghorn calculi.

13. Check soft tissue of the pelvic inlet.

Detail of 13 steps

1. Start off with lower 1/3 of SI joints. 3 conditions affect the lower 1/3 of SI joint:

- AS

- DJD

- OCI (Osseitis Condensans Illi; AKA Osseitis Triangularis, Hyperosstosis

Triangularis)

AS – causes bilateral symmetrical fusion of the SI joints.

- If you can see joint spaces – rules out AS.

- If you cannot see joint spaces at all – Is the reason technical of pathological?

If pathological – AS

Fusion of SI joints due to AS – called ghost joints.

When you see bilateral symmetrical whitening of the iliac side of SI joints two conditions come to mind:

- DJD

- OCI

- When differentiating DJD from OCI, compare the color of the ilium to the lower portion of the sacrum of the SI joint. (45º angle down). If the whitening on the ilium is obviously whiter than the lower portion of sacrum of the SI joint then diagnosis is OCI. If the whitening on the ilium is similar to the lower portion of sacrum of the SI joint then diagnosis is DJD. (move in a bit on the sacrum if you can see the sacrum)

OCI – multiparus women 20-40 yrs, bilateral stress hypertrophy of the ilia. Responds well to chiropractic; adjust them. Self-limiting, self-resolving benign condition. All labs would be normal (no ↑ in alk phos)

2. Compare color and shape of one ilium to the other.

Shape – PFF (Paget’s, Fractures, Fibrous Dysplasia)

Color – Whiter = blastic mets or Paget’s

Darker = Lytic mets, myltiple myeloma, or benign bone tumor

3. Check Reiser’s sign. Helps determine the age of the patient. Found between iliac epiphysis and iliac crest.

When Reiser’s sign is open, will see thin black line – person is under 20 yrs

If look in area of Reiser’s sign and see thin white line – person is 20-30 yrs

If no thin white line and no signs of DJD – person is 30-40 yrs

If have signs of DJD on film – person is over 40 yrs

4. Go to top of iliac crest an draw a straight line across. It should bisect the L4/L5 disc space. Purpose of this step is to orientate yourself.

5. Count up the spine until you find last set of ribs that point down = T12.

(Part IV – just assume it is T12, don’t think about congenital anomalies)

6. Count down spine checking for a lumbosacral transitional segment.

If you can count 6 lumbar vertebra – lumbarization of S1.

If L5 TP’s are fused or are articulating with sacrum then it is sacralization.

Whenever L5 TP is enlarged or flattened – called spatulated TP.

Subarticular sclerosis – when L5 TP articulates with sacrum (not subchondral sclerosis)

If you see sclerosis on inferior aspect of L5 TP- also referred to as sacralization.

Hypertrophic TP’s of L5 – AKA spatulated TP

7. Check sacrum for alteration of shape and vertical radiolucency.

Shape – PFCF (Paget’s, Fractures, Congenital anomaly, Fibrous Dysplasia)

Color – Whiter – blastic mets or Paget’s

Darker – lytic mets, MM, or benign gone tumors

MC benign tumor of the sacrum – Giant cell tumor

8. Check L5/S1 facets for tropism (Part IV – AKA asymmetrical facets)

Normal facets are coronal. If see a sagital facet (see joint space on AP film) – facet tropism.

9. Perform square blockhead system all the way up the spine. Also check the disc spaces all the way up the spine for :

- DJD (same as before)

- Infection (same as before)

- Marginal syndesmophytes of AS (bilateral and symmetrical for every segment affected)

10. Check soft tissue from L2-L4 bilaterally for a half moon shape, curvey linear calcification of abdominal aortic aneurysm.

If you can see abdominal aorta on AP film – take it to the bank it is abdominal aortic aneurysm.

11. Check soft tissue opposite L2 vertebra for renal artery calcifications and renal artery aneurysms.

Both have black center outlined in white.

If smaller than L2 vertebra – renal artery calcification.

If larger than L2 vertebra – renal artery aneurysm. (center will be grey, not necessarily dark)

12. Check soft tissue from 12th rib to iliac crest bilaterally checking for

- gallstones AKA cholelithiasis

- kidney stones AKA nephrolithiasis

- staghorn calculi

Gallstones – mostly cholesterol; 90% do not show up on x-ray; will show up if it calcifies. Will appear with a black center outlined in white. Usually found around L1-L2 area. Only found on right side of abdomen. Start at top of iliac crest and go up.

Kidney stones – mostly calcium; most show up on x-ray. They appear as round white densities (pure white). Found L1-L3 area. Start at lower 1/3 of SI joint and go up.

3 types:

- calcium oxalates

- calcium urates

- calcium phosphates

Staghorn calculi – calcification of renal calycies. Unilateral or bilateral

If you can see outline of uretres – IVP study (intraveneous pylogram)

If you don’t see outline of ureters – staghorn calculus

13. Check soft tissue of the pelvic inlet looking for 4 things.

- uterine fibroids

- calcified prostate

- ureter stones

- phleboliths

MISC INFO

Burst Fracture – look for displacement; line up inside of pedicles or outside of vertebral bodies

Blastic and Lytic mets on same film = Metastatic disease

OCP – Osseitis Condensans Pubi

If seen in men – result of prostate surgery

If seen in women – result of child delivery

If you see what appears to be DJD of symphysis pubis – have OCP

Bilateral stress hypertrophy of symphysis publis.

Claw osteophytes – indicative of DJD, but disc space will be normal. If you can outline cortex around it – you know it is an osteophyte (not a non-marginal syndesmophytes or marginal syndesmophytes) Usually 40 yr olds acting like they are 20 yr olds – with their activities.

Radiographic sign for AS

- earliest sign – Romanus lesion – erosion at the corner of a vertebra. Cannot be seen on x-ray

- earliest x-ray sign of AS – shiny corner sign.

- bamboo spine appearance – due to marginal syndesmophytes

- trolley track sign – calcification of capsular ligaments

- dagger sign – due to calcification of superspinous and interspinous ligaments

- star sign – only seen when SI joints are fused.

Butterfly vertebra – congenital anamolies. Two ways it can appear.

They are failure of ossification of the center of vertebra. (Part IV – midline

defect, called sagittal cleft defect.

If see what appears to be a disc in a congenital block vertebra – called remnant disc or rudimentary disc.

Knife-clasp deformity – spina bifida of S1 with an elongated spinous of L5.

**Never want to adjust them into extension. Two clinical outcomes of this:

- sacral nerve irritation

- compression over a sacral defect

Costocondral calcification – idiopathic, common but cause in unknown

Ribs 8, 9, 10 – articulate with costo-cartilage of rib above. That costo-cartilage can calcify on anterior.

On x-ray – posterior part of rib comes down and away; anterior parts curve back up toward the spine.

AP PELVIS

Motive – for pain or disfunction

Age is the biggest differential in the pelvis.

4 growth centers you should check for:

- acetabular epiphysis

- ischiopubic epiphysis (closes by age 9)

- femoral capital epiphysis

- greater trochanteric epiphysis

If look at growth center and they are open (thin black line) – person is under 20

If look and see a thin white line – 20-30 yrs

No thin white line, no signs of DJD – 30-40 yrs

Signs of DJD - >40 yrs

Young Older Both

-Legg Calve Perthes - Lytic mets - Fibrous dysplasia

-Slipped Capital Femoral - Multiple myelomo - Congenital Hip Dysplasis

Epiphysis - Blastic mets

- Paget’s

- DJD

- Osteoporosis

- RA

- AVN of the hip

Anytime you have a pelvic shot in someone under 20 – two conditions you must look for:

- Legg Calve Perthes

- Slipped Capital Femoral Epiphysis

11 Steps

**MUST COMPARE SIDE TO SIDE**

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

2. 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.

5. Check sex of patient.

6. Check color and shape of one ilium to the other.

7. Check color and shape of one pubis to the other.

8. Check color and shape of one isheum to the other.

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

and color.

10. Compare femoral neck and shaft to the other side for alteration of shape and

alteration of color.

11. Check soft tissue of pelvis inlet.

Detail of 11 Steps

1. Start at lower 1/3 of SI joints; concerned with

- AS

- DJD

- OCI

(Same as previous)

2. 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 acetabulum.

If femoral head is outside acetabulum:

- congenital hip dysplasia (unilateral or bilateral)

- hip dislocation

Radiographic signs of congenital hip dysplasia:

- Puttis Triad

- smaller than normal femoral head (hypoplastic femoral head)

- shallow acetabulum

- femoral head will be outside acetabulum

Radiographic signs of hip dislocation:

- Femoral head will be of normal size

- Acetabulum will be of normal depth

- Femoral head will be outside acetabulum

5. Check sex of patient. Look at soft tissue shadow under the symphysis pubis

Male – Look for penis

If see what appears to be upside down wine glass – male pelvis

Angle under symphysis pubis – approx 90º - male pelvis

Female - If see what appears to be upside down margarita glass – female pelvis

Angle under symphysis pubis – 140-150º - female pelvis

6 – 8. Check color and shape of one ilium, pubis, and isheum to the other.

Shape – PFF (Pagets, Fracture, Fibrous Dysplasia)

Color – Whiter – Pagets or blastic mets

Darker – Lytic mets, MM, or benign bone tumors

9. Compare proximal femur head and acetabulum to the other side for alteration of size and color. Two conditions:

- DJD of hip

- AVN of hip

DJD AVN

- loss of superior lateral joint space - superior lateral joint space is preserved

- sclerosis on femoral head side and - only get sclerosis on femoral head side

acetabular side

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

Shape – PFF (Paget’s, Fractures, Fibrous Dysplasia)

Color – Whiter – Blastic mets or Paget’s

Darker – lytic mets, MM, benign bone tumor

11. Check soft tissue of pelvic inlet looking for:

- uterine fibroids AKA mulberry mass appearance

- calcified prostate

- ureter stones

- phleboliths

Uterine fibroid vs. calcified prostate

**best way to differentiate the two – look at sex of patient

- color of uterine fibroid – white

color of calcified prostate – white

- shape of uterine fibroid – round

shape of calcified prostate – round

- **location of uterine fibroid – round white density in center of

pelvic inlet

location of calcified prostate – round white density sitting on top of

symphysis pubis.

Uterine fibroid – MC benign tumor of the pelvic inlet in women.

Ureter stones vs. phlebolithes

If see small round white densities above that line – ureter stones

If see small round white densities below that line – phlebolithes

MISC INFO

Paraglenoid sulci – only seen in women, but not seen in all women. They form from superior gluteal artery getting pushed against bone in pregnant women.

Lytic mets vs. Multiple Myeloma

Lytic mets will see holes grossly different in size

MM will see holes similar in size

If see bilateral pubis and bilateral isheal fractures – saddle fracture.

Protusio acetabuli – use Kohler’s line to diagnosis it – it is drawn along inner portion of pelvis, the femoral head should not cross that line.

If femoral head does cross that line - + Kohler’s line = protusio acetabuli

Common conditions that cause this:

- Pagets

- Fibrous Dysplasia

- Trauma

- Severe DJD

- Osteomalacia

Bilateral protusio acetabuli – AKA otto’s pelvis The MC cause of otto’s pelvis = RA

Slipped Capital Femoral Epiphysis – usually seen in overweight males. Use Klein’s line to diagnose – drawn along superior aspect of the neck of femur. It should hit some portion of the femoral head to be normal. + Klein’s = slipped capital femoral epiphysis

SCFF is the MC Type I Salter-Harris fracture (only seen in bones with open growth centers).

Best view to diagnose Slipped Capital Femoral Epiphysis – Frog Leg View

Clinical – usually seen between 10-16 yr old overweight males. Painless, limp and have referred pain to groin and to knee.

On exam – decrease of internal rotation and abduction of hip

Most cases they leave it alone and let it heal.

Healed Slipped Capital Femoral Epiphysis in adult – all growth centers will be closed, but still have + 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 (MC 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- AVN of hip in a child (4-9 yrs old)

Cause is trauma

4 radiographic signs (may not see all of them) – takes 2 months for AVN to show up on x-ray

- * flattening of the femoral head

- * fragmentation of femoral head (cresent sign)

- whitening of femoral head (snow cap sign)

- joint space will be wider

Best imaging modality for AVN – MRI ; if can’t order MRI, order bone scan

Healed Legg Calve Perthes Disease

- Flattening of femoral head

- No fragmentation of femoral head

- No whitening of femoral head

- Joint space will still be wider

Part IV – mushroom shaped deformity

Presents will painless, limp, pain referred to groin and knee. On exam – decreased internal rotation and abduction of hip.

Part IV – common outcome = early DJD

EXTREMITY FILM

Motive – pain or disfunction

Read them from proximal to distal anatomically.

6 Steps

1. 1st check periosteum

2. Check cortex

3. Check medulla

4. Check joint spaces

5. Check growth centers

6. Check soft tissue

Detail of 6 Steps

1. First check periosteum.

Periosteal Reaction – new bone growth in response to cortical destruction (not normal)

Two basic types of periosteal rxns:

- linear AKA parallel AKA laminated

two conditions come to mind

- trauma

- infection

- spiculated AKA sunburst AKA radiating

primary malignancy of bone such as a sarcoma

Linear periosteal rxns:

- only occur on long tubular bones

- you must see – thin white line, dark line, cortex of bone

- to differentiate trauma vs infection

look for signs of trauma - radiolucent line to indicate fracture line

- boney callus (appears as a cloudy, white

density)

Ewing’s Sarcoma – 10-25 yrs old, usually occurs in diaphysis of bone. In order to diagnose you must see the following 3 signs:

- multilaminated (onion skin appearance) of a periosteal reaction

- lytic areas (100% in the medulla) surrounded by sclerosis

- boney expansion

If don’t see all three – not Ewing’s

Lytic mets, MM, blastic mets do not affect the cortex

When see periosteal rxn – Ask “Is it linear?” if no then it is speculated

Spiculated periosteal rxn – primary malignancy of bone (sarcoma)

3 conditions come to mind

- ostoesarcoma (10-30 yr)

- fibrosarcoma (> 40 yr)

- chondrosarcoma (> 40 yr)

Cannot differenciate fibrosarcoma vs chondrosarcoma on x-ray

(use CT scan and bone biopsy to differenciate)

The only time you will see an osteosarcoma in someone over 30 yrs is when it is

the malignant stage of Pagets

When you see a periosteal reaction, if you are unsure of whether it is speculated or linear – then check for boney expansion.

Trauma and infection do not expand bone.

Primary malignancies of bone (sarcoma) can cause boney expansion.

2. Check cortex. 4 things can affect cortex:

- thickened – Pagets

- thinning – osteoporosis

- interruption of cortex – fracture vs non-union

- deformity – Pagets and fibrous dysplasia “wavey” bones = deformity

Once you have deformity on the film the only way you can differenciate Pagets from fibrous dysplasia is by comparing the overall color of the medulla to the adjacent soft tissue.

If the overall color of the medulla is obviously whiter than the adjacent soft tissue = Pagets

If the overall color of the medulla is similar to the adjacent soft tissue = Fibrous Dysplasia

When you compare, cover up the cortex.

Part IV – Fibrous Dysplasia AKA ground glass appearance

If you have deformity of the tibia – called “saber shin deformity”; can be seen with Paget’s of fibrous dysplasia.

When checking for deformities in the pelvis:

If you have deformity of the femurs – called “Sheppard’s crook deformity”. Can be seen with Pagets or fibrous dysplasia.

The first area where you will see deformity in the pelvis will be in the shaft’s of the femurs. To pick up this deformity, come to where the lessor trochantor meets the shaft of femur, drop straight line down, the line should run along the shaft of the femur. This is normal.

If the shafts of the femur bow lateral (away) form the line = deformity (bowing in is not a sign of deformity – this is normal positioning)

Radiographic signs for Pagets:

- cottonwool appearance

- fasciculations due to coarsened (thickened) trabecular pattern (stringy)

- blade of grass appearance (useless)

- osteoporosis circumscripta (useless)

- sheaths of grain (useless)

- **brim sign of Pagets due to cortical thickening (especially of pelvic brim)

- pseudofractures

Pagets AKA Osseitis Deformans: cortical thickening, usually seen in men > 50 yrs. 4 Stages:

- lytic phase

- mixed phase

- blastic phase

- malignant degeneration – degenerates into an osteosarcoma.

Labs: ↑ alk phos (the highest elevation of all conditions)

↑ of urinary hydroxy proleen

normal calcium

normal phosphorous

If you see horizantal fractures in a long bone – indicative of pathological fracture = (Part IV) banana fracture

Long bones usually fracture oblique ( spiral fracture).

Fibrous Dysplasia:

Benign bone tumor – can occur at any age

“spider web” or “cobweb” or “spokey appearance”

Benign bone tumor Monoostonic ofrm of fibrous dysplasia

Thicker border, looks sclerotic – called “rind sign”

AKA’S

Infection osteomyelitis

infective arthritis

infective spondylitis

septic arthritis

discitis

Pott’s disease

Congenital Block non-segmentation

Failure of segmentation

Vacuum Phenomenon Vacuum cleft sign

Knuttson sign or phenomenon

Phantom disc

Lipping & Spurring Telescopic projection

Osteophytes

Spondylophytes

Traction spurs

Uncinate Arthrosis Von Lushka Arthrosis

Covertebral joint arthrosis

Uncovertebral joint arthrosis

Scheurmann’s Disease Avascular necrosis

Osteonecrosis

Aseptic necrosis

Subchondral necrosis

Osteochondrosis

Juvenilis Kyphosis Dorsalis

Iscemic necrosis

Multiple endplate irregularities

Multiple Schmorels nodes

AS Marie Strummpel’s disease

Side notes – morning stiffness, morning low back pain, may have problems breathing, age – 15-35 yr males. ROM – loss of flex/ext then lose lat flex/rot.

Earliest signs of AS – pseudojoint widen, erosion of SI joints, ankylosis

Ortho’s – Forster’s Bowstring

Chest Expansion

Lewine’s supine

#1 lab test – HLA-B27, next best = ESR

Adjust above and below segments involved.

DISH Forrestier’s Disease

Ankylosing Hyperostosis

Side notes – MC area – lumbar spine (according to textbooks) Most films show it in cervicals or thoracics. Facets don’t fuse. Affects men over 50.

Only motions that would be lost – flexion & extension.

OCI Osteitis Triangularis

Hyperostosis Triangularis

3 conditions that can be found anywhere

1. osteopoikilosis

- tiny white dots within bone; benign condition; self-limiting, self-resolving; no positive labs with this condition. Systemic condition – affects more than one bone.

When you see this you may think blastic mets, always think blastic mets until you prove otherwise:

Differentiate blastic mets from other conditions:

- best way – look at age (if see it in young person, not blastic mets)

- if see cortical thickening, enlargement or deformity of bone – Paget’s

- size of the white densities – if the overall size of the white densities are roughly similar in size = osteopoikilosis; if overall size of white densities is grossly unequal in size = blastic mets.

- if still unsure, check to see if every single bone is affected – then osteopoikilosis

2. synoviochondrometaplasia AKA synovioosteochondromatosis

- white, popcorn-like calcification in a joint and around the joint

- MC causes are DJD and trauma

- dull, achy pain around joint; palpate hard nodules around the joint

- usually more common in weight bearing joints.

- athlete – surgically remove densities otherwise usually left alone

3. myocytis ossificans

- calcium or bone within muscle

- cause – blunt trauma to muscle (contraindications for bruising: heat, ultrasound, massage) MC areas – biceps and quads

- differentials – primary malignancy of bone – periosteal reaction

synoviochondrometaplasia

To differentiate periosteal reacion of primary malignancy of bone from myocytis ossificans:

- best way – color motive of film

if see bone film – primary malignancy of bone

if see underpenetrated film – myocytis ossificans

- with myocytis ossificans the calcification is parallel to the shaft of bone; however, periosteal reaction comes out 90º to the shaft of the bone

- with myocytis ossificans you will see a radiolucent line between the white density and the shaft of the bone

To differenciate myocytis ossificans with synoviochondrometaplasia:

- Location – look in the nearest joint, if joint space is affected – synoviochondrometaplasia

JOINTS AND THEIR CONDITIONS

HIP

Look back in notes – most of the conditions for the hip have already been talked about.

Hip Fractures:

5 Types

1. subcapital

2. midcervical AKA transcervical (MC)

3. basocervical

4. intertrochanteric (2nd MC)

5. subtrochanteric

KNEE

Most diagnosis comes off AP shot of the knee, however there is one dondition that cannot be diagnosed off AP shot, it is diagnosed on lateral – Osgood Schlatters

AP Shot – 1st differentiate medial side from lateral side – fibula is always lateral. Medial is the weight-bearing portion.

1st two conditions – DJD vs RA

For you to know that you have decreased joint space on the film, you want to see intercondylar eminance jammed into intercondylar fossa – you will not see a space.

- If you see ↓ of medial joint space, subchondral sclerosis, and lipping and spurring (if severe), but lateral joint space is preserved – DJD

- Loss of lateral joint space, but medial joint space is preserved – this indicates any other condition other than DJD. Most likely have RA

- If have loss of medial and lateral joint spaces – two conditions come to mind – DJD vs RA

- check for obvious subchondral sclerosis (check on tibial side and look down a little bit)

If see obvious subchondral sclerosis on both medial and lateral aspects of tibia – DJD

If don’t see this – RA

Osteochondritis Dessicans – avascular necrosis of the distal condyle of the femur

80% - medial side of knee (lateral aspect of medial femoral condyle)

20% - lateral side of knee

Part IV – radiolucent line called black cresent line – nothing more than the osteochondral fracture line. Always seen in all stages of osteochondritis dessicans; healing stage – will not see boney fragment.

Can cause a joint mouse – boney fragment becomes free floating in knee joint.

Classic age group – 17-30 yr old athletes, knee locks up on extension

Part IV – meniscal tear may also cause locking on extension

* If you have AP shot of knee, before you put down normal knee as diagnosis or DJD as diagnosis, check condyles one more time for a possible osteochondritis dessicans.

Best view to diagnose ostechondritis dessicans – Tunnel View.

Pelligrini Steades Disease – nothing more than calcification of the medial collateral ligament of the knee.

MC cause – DJD and trauma

Readiographic sign – whisp of smoke appearance.

Presents with severe knee pain.

Charcots Joint – usually diagnosed in the knee on a lateral film. Usually seen in weight bearing joints.

AKA neuropathic or neurotrophic joint

A hypermobile, painless joint.

Any condition that interferes with the sensory input from joint to the brain will cause charcots joint. (Person doesn’t feel pain and will keep using joint and destroy it)

6 D’s:

- Destruction – tibial plateau appears very concave rather than flat

- Dislocation

- Density Increase – all around joint appears white

- Debris (bone) – see boney fragments

- Disorganization

- Distension

In order to diagnose a Charcots Joint you must see a bone film.

The following conditions can cause Charcots Joint:

- diabetes mellitus

- tabis dorsalis

- syringomyelia

- leprosy

- cortical steroid use

If it appears as though you put a bomb inside the joint and it exploded – Charcot’s Joint

Osgood Schlatters Disease – must see lateral shot of the knee

Post-traumatic avulsion fracture of the tibial tuberosity. Repeated microtrauma. Usually seen between ages of 10-16.

Muscles develop strength quicker than bone – as muscle contracts is gradually pulls off the tuberosity.

MC sport – soccer players

Treat – have person stop activity for 3-5 weeks. Buy Osgood Schlatters brace. Get them into pool swimming – freestyle swim. Painful to wear brace – wean them into brace.

Not an x-ray diagnosis – clinical diagnosis. Pin point pain over tibial tuberosity.

Part IV – makes you diagnose it on x-ray.

CPPD – calcium pyrophosphate deposition disease

MC seen in knee; aka pseudogout

Causes fine linear calcification of hyaline or fibrocartilage. The best view to diagnose this on – magnafication view.

Most common structures to calcify in knee – meniscus

Fractures of patella

Transverse fracture of patella (MC) Stellate fracture of patella

(ie shattered kneecap in MVA)



Fracture vs Nonunion

To differenciate:

If see radiolucent line in area of growth center but all other growth centers are closed – non-union.

Normal growth center – upper lateral aspect of patella.

Two types of non-unions:

- bipartite patella (2 pieces)

- tripartite patella (3 pieces)

SKULL

Paget’s, Lytic mets, Multiple Myeloma (All on Part IV)

Normal cortex, thicker in back, thinner in front.

Paget’s of the skull – must see cortical thickening all the way around the skull (especially in front)

Lytic mets vs Multiple Myeloma

If see multiple lytic lucencies in the skull – think malignancy (lytic mets & MM)

Best way to differentiate:

- size of holes, if the overall size of the holes is roughly similar in size then have Multiple Myeloma.

- if the overall size of the holes is grossly unequal in size (swiss cheese) – Lytic mets

Sometime with Multiple Myeloma, the holes will come together and give you a big hole.

Part IV – Multiple Myeloma (Rain drop skull)

LAB:

- Normocytic Normochromic anemia

- Rouloux formation

Bone infarct – AKA Caissons Disease

Diabetics and scuba divers usually get these. AVN of the medulla of the bone – medulla turns whiter.

Part IV – radiographic sign – surpiginous calcification

Chewing gun sign

__________ ______ ____ __________ ______ ____ __________

ANKLE/FOOT

Biggest things you will see are Fractures and Arthritis.

MC fractured bone in the ankle = fibula

Potts Fracture – fracture of distal fibula with ligamentous disruption (AP view)

Bimalleolar Fracture – fracture of distal fibula and distal tibia (AP view)

Trimalleolar Fracture – fracture of distal tibia, distal fibula, and posterior aspect of tibia. Need two views – AP and lateral views.

March Fracture – fracture of 2nd, 3rd, 4th metatarsal of foot

Dancer’s/Jones Fracture – fracture of 5th metatarsal

Part IV – anytime you see distal fibula fracture – call it a Pott’s fracture

To have fracture of 5th metatarsal, you must see a radiolucent line coming into the shaft of the bone (perpendicular of shaft).

Normal growth center of 5th metatarsal

(vertical line).

P-A FOOT/P-A HAND

Same motive as extremity

10 steps

1. Start at MCP/MTP

2. Check PIP’s

3. Check DIP’s

4. Check carpal/tarsal bones

5. Check periosteum of bones

6. Check cortex

7. Check medulla

8. Check joint spaces

9. Check growth centers

10. Check soft tissue

4 Arthrotides that affect hands and feet:

- RA - inflammatory

- OA

- Psoriatic Arthritis - Erosive

- Gout - Metabolic

Detail of 10 steps

1. Start at MCP/MTP. Biggest condition – RA

RA - get distribution pattern = 3 or more of the same type of joint is affected.

- destruction from joint space to joint space will be relatively equal

- if severe enough will get deviation of phalanges toward ulnar side of hand of fibular side of foot in a distribution pattern (draw line through midshaft of metacarpal, it should run through midshaft of phalange)

Part IV – rat bite erosions of RA

Juxta-articular osteoporosis – dark on both sides of joint. Inflammatory

condition - ↑ in blood supply turns bone darker.

2. Check PIP joints – non-diagnostic because everything affect PIP joints (OA, RA, PA, Gout)

3. Check DIP joints – RA NEVER INVOLVES THE DIP JOINTS

If see DIP joints involved – rules out RA

If see distribution pattern in DIP joints – OA or PA

OA PA

- distribution pattern - distribution pattern

- destruction from joint to joint - destruction from joint of joint is

is relatively equal relatively equal

- turns joint space whiter - turns joint space darker

Nodes – DIP – Hyeburdens – OA

PIP – Buchards – Any condition

MCP/MTP – Hagarths – RA

Gout – 70% monoarticular (one joint)

Loves to affect big toe – podagra

30% may affect more than one joint – no distribution pattern

Destruction from joint space to joint space is grossly unequal.

**Only condition that destroys from the outside-in. Bone around joint will start to be destroyed but joint space will be intact.

Part IV – juxta-articular erosions (destruction from outside-in with joint space intact)

Overhanging edge sign (useless sign)

Severs Disease – AVN of calcaneous epiphysis – whiter

SN – today it is considered normal variant.

- No Clinical significance

Boehler’s Angle – usually used to diagnose calcaneal fracture (usually impaction fracture). Normal angle – 28-40º

< 28º - calcaneal fracture

> 40º - congenital malformation

Place dot at back of calcaneous and in the middle – draw line. Place dot at front of calcaneous and in the middle – draw line. Measure angle.

Common in kids.

Heel Spur – MC cause – plantar fascitis

Other causes – Reiter’s Syndrom – caused by clamydia

Heel spur w/Reiter’s Syndrome – called Lover’s Heel

SHOULDER

3 views – AP internal, AP external, Baby-arm lateral

If see baby-arm lateral – immediately rule out fractures, dislocations, and separations

When you see shoulder shot – 1st question you ask – Which joint do I see better?

- glenohumeral

- AC

Which ever one you see better you can take it to the bank that is where the problem is.

8 Steps

1. Trace clavicle off the film from lateral to medial.

2. Check for AC separation

3. Find top of coracoid process, go out lateral to find top of glenoid fossa.

4. Draw line at top of glenoid fossa checking for glenohumeral dislocation

5. Check periosteum, cortex, medulla of humerus

6. Check middle of glenoid fossa

7. Check periosteum, cortex, medulla of scapula

8. Check ribs on film

NEVER MAKE A LUNG PATHOLOGY DIAGNOSIS ON ANY OTHER FILM OTHER THAN A CHEST FILM.

Detail of 8 steps

1. Trace clavicle off film from lateral to medial looking for vertical radiolucencies going through clavicle – fracture

Horizontal radiolucencies – mach lines

2. Check AC joint for separation. Draw line through midshaft of clavicle.

Ask – does it hit some portion of the acromium?

- yes = normal

- no = AC seperation

Part IV – radiographic sign – distal clavicle elevation

3. Go to top of corocoid process and go out lateral to find top of glenoid fossa.

4. Draw line at top of glenoid fossa checking for glenohumeral dislocation.

Dot at top and dot at bottom, connect dots. Dray line perpendicular to that line at top of fossa. Check distance from line to top of humeral head. 25% or more displacement above or below that line (take fossa and cut it into quarters) – glenohumeral dislocation

If the humeral head goes inferior, you also know it sent anterior – MC dislocation

If it went superior, you also know it went posterior.

2 signs of chronic dislocations –

- Hill-Sachs deformity AKA hatchet deformity

- Bankart lesion – avulsion of the inferior aspect of

glenoid labrum. Major cause – chronic pulling of

long head of triceps muscle

5. Check periosteum, cortex, medulla of humerus. (see previous notes and notes on benign bone tumors)

6. Check middle of glenoid fossa for radiolucent line coming into fossa to indicate glenoid fossa fracture. AKA scapular fracture

mechanism of injury – falling on outstretched arm

7. Check periosteium, cortex, medulla of scapula. (see previous notes and notes on benign bone tumors)

8. Check ribs on the film. The way you read ribs on film will be the same as rib shot.

No periosteum inside joint space—if see spuring it is not periostial reaction.

HADD – hydroxyapatite deposition disease. Calcification of tendons or bursas.

Technically can occur anywhere, but MC in shoulder.

12 – subacromial bursa

3 & 9 – subdeltoid bursa

2 & 10 – supraspinatous tendon

Chronic inflammation – causes tendon or bursa to calcify. Tendonitis & Bursities cannot be seen on x-ray. Calcific tendonitis and Calcific bursitis can be seen on x-ray.

On AP view – white density at 12, 3, 9 = calcific bursitis

- white density at 10 & 2 = calcific tendonitis

SPOT SHOT OF RIB

Motive – to view ribs

Biggest thing you will see – rib fractures

MC benign tumor of rib – Fibrous Dysplasia

MC malignancy of rib – Multiple Myeloma

Process

Start at the top and come down.

Check two ribs at a time and the interspace inbetween. Look for subtle change in space inbetween.

ELBOW

4 views – AP, medial oblique, lateral elbow, Jones tangential view

Part IV – most diagnosis will be done on AP and lateral.

Biggest things – fractures, arthritis, fat pads.

Fat Pads – Two: anterior and posterior

- Anterior – can be seen normally – but it must be parallel to the shaft of the humerus. If anterior fat pad gets displaced away from humerus and looks like sail of sail boat – Anterior sail sign – indicates inflammation from trauma, infection, or inflammatory arthritis.

- Posterior – Never seen normally. If you see one – indicates inflammation from trauma, infection, or inflammatory arthritis.

Two major arthritides – DJD vs RA

When see loss of joint space – think DJD vs RA

Differentiate the two:

- look for obvious subchondral sclerosis on the ulnar and radial sides of elbow –

DJD

- If don’t see this – RA

Part IV – never put down benign bone tumor affecting olecranon process unless you are willing to bet your life. Usually pseudocyst.

Fracture vs. Non-union:

Displacement of bone-fracture.

Olecranon fracture - ↓ extension of elbow; muscle - triceps

Impaction fracture of radial head – fall on outstretched arm – look at contour of radius, should be smooth, if not, fracture.

Chisel fracture – mechanism – fall on outstretched arm.

- Vertical fracture

- AP view

FOREARM

- Biggest thing you will see are fractures

7 kinds of fractures

1. Night stick fracture

Fracture of the midshaft of the ulna

2. Galeazzi fracture

Fracture of the distal 1/3 of the radius with dislocation of the ulna

3. Monteggia fracture

Fracture of the proximal 1/3 of the ulna with dislocation of the radial head

4. Colles fracture (more common) (must see lateral film)

Part IV dinner fork deformity, Fracture of the distal portion of the radius w/ post displacement of fragment.

5. Smith’s fracture aka Reverse Colles (must see lateral film)

Fracture of distal portion of radius w/ anterior displacement of fragment

6. Greenstick fracture

Only occurs in young bones, break in the cortex on one side, buckling of the cortex on the other side

7. Torres fracture

Can be seen in young or old, buckling of cortex on both sides (bumb on both sides)

Mechanism – Falling on outstretched arm (impaction)

WRIST

4 views

- PA

- PA ulnar deviated

- Lateral

- Medial Oblique

Most diagnostic – PA ulnar deviated

- Looks at scaphoid and lunate

When you draw a line through the mid-shaft of the radius it should go through lunate, capitate and shaft of 3rd metacarpal. If you see 3rd metacarpal deviate to ulnar side – PA ulnar view.

MC fractured bone of the wrist – Scaphoid

MC dislocated bone of the wrist – Lunate

Scaphoid

- 3 things happen

1. Fractured – usually in mid portion of the bone

2. Dislocation – must see 2 radiographic signs (Must see both)

a. Signet ring sign – actual dislocation of scaphoid

b. Terry Thomas sign – Widening of the scaphoid/lunate jt

space

3. AVN of scaphoid aka Preiser’s Disease

Lunate

- 2 things can happen

1. Dislocated

- Pie sign, lunate will also extend almost to midpoint of the

capitate/hamate

2. AVN of Lunate aka Kieboch’s disease

- Compare two bones, two bones only

- When checking for AVN of scaphoid and AVN of lunate

compare two bones, scaphoid to lunate and lunate to scaphoid

- If Scaphoid is obviously whiter than lunate → AVN of Scaphoid

- If Lunate is obviously whiter than proximal ½ ← scaphoid →

AVN of lunate

HAND

Biggest things

- Fractures and arthritis

Fractures (Be Bo Ba)

- Bennets – Fracture of 1st Metacarpal

- Boxers – Fracture of 2nd or 3rd metcarpal

- Bar room – Fracuter of 4th or 5th metacarpal

- Rolando’s Fracture – AKA communuted Bennets fracture

Arthritis

See Previous notes on PA foot

Gout in NOT erosive arthritis

PA is erosive arthritis

If you see PIP, DIP, MCP of same finger affected, destruction from joint to joint is relatively equal and the destruction is from inside out → Ray sign of PA

Radiographic signs of PA (part IV)

- Mouse ear sign (Early stages)

- Pencil in cup deformity (Advanced stages)

- Balancing pogoda sign (Advanced stages)

- Ray Sign

- Cocktail sausage digit (not x-ray sign, it is a clinical finding)

Scleroderma

- Causes reabsorption of distal tufts of Phalanges

- AKA – Progressive systemic sclerosis

- Tightens all tissues in the body

- Crest Syndrome

Calcinosis Cutis (calcification of soft tissue)

Raynoud’s

Esophageal disphagia

Sclerodactly

Telangiectasis (pigmentation of the skin)

Erosive Osteoarthritis

- Sea Gull Sign or Gull wing appearance

- Can occur in DIP or PIP joints

BENIGN BONE TUMORS

Benign Malignant

- Encapsulated   - Nonencapsulated

- Short zone of transition (black to white) - Long zone of transition (Gray)

- All the way around the lesion

- Usually single lesion with 3 exceptions - Usually multiple lesions

3 Exceptions

- Fibrous dysplasia

- HME – Multiple osteochondromas

- Ollier’s Disease

- Multiple enchondroma’s

- Usually asymptomatic with one exception - Bone pain(hallmark of Malignancy)

- Osteoid Osteoma

UBC (Unicameral Bone Cyst) ABC (Aneurysmal Bone Cyst)

- Seen under 20 yoa  - Seen under 20 yoa

- Metaphyseal and diaphyseal - Metaphyseal and diaphyseal

- Concentric (extends cortex to cortex) - Eccentric (take straight vertical line

- aka Simple bone cyst and cut bone in half, is

majority of lesion to one

side of line. If yes –

eccentric)

- Get radiographic sign – Fallen fragment sign

- Confined more to one area of bone

- Rarely goes entire bone

Giant Cell Tumor aka Osteoclastoma Chondroblastomas

- Over 20 yoa  - under 20 yoa (open growth center)

- Metaphyseal, epiphyseal - metaphyseal, epiphyseal

- Radiographic sign – Soap bubble appearance

Fibrous Dysplasia NEVER goes to the epiphysis of long bones

UBC, ABC, Giant cell tumors and chondroblastomas all can cause boney expansion

Non-ossifying fibroma (NOF) Fibrous Cortical Defect

- Thses are exactly the same lesion

- Over 9 yoa - Under 8 yoa

- They are an incidental finding on x-ray

NOF/ Fibrous Cortical Defect vs. ABC

Differentiated by 3 ways

- Best way is size: NOF/ FCD are small

ABC are large

- Check for boney expansion: NOF/ FCD do not expand

ABC can expand bone

- Look for scalloping inside the lesion

If you see scalloping – Pathoneumonic of NOF

ABC – does not cause scalloping

MC benign tumor of the spine → Hemangioma

- Vertical striations in vertebra – Chorduray cloth

- If you see one hemangioma – Keep diagnosis as hemangioma

- If you see two – Keep diagnosis as hemangioma

- If you see 3 or more – change diagnosis to osteoporosis

If patient has night pain relieved by aspirin → Osetoid Osteoma

- A prostaglandin producing tumor; aspirin is an anti-prostaglandin agent

To DX osteoid osteoma – must see 2 things

1. Radiolucent nidus

2. It must be surrounded by severe reactive sclerosis

3 ways to differenciate osteoid osteoma vs. Blastic Mets

- Blastic mets does not cause periostal rxn

- Blastic mets does not cause boney expansion

- Blastic mets does not cause radiolucent nidus

MC benign tumor of apendicular skeleton → Osteochondroma

2 basic types

- Pedunculated oseteochondroma

- always point away from nearest joint

- aka coat hanger exostosis

- Will see base/ stalk of lesion with calcified cartilaginous

cap called “cauliflower shape”

- Sometimes may not see cap

- Sessile Osteochondroma

- aka broad based exostosis

- If you see what appears to be radial tuberosity on the bone

other than the radius – sessile osteochondroma

- “bump on bone” where it should not be

- Calcified cartilaginous cap can be used with sessile

osteochondroma also.

Multiple Osteochondromas→ Change DX to HME (Hereditary multiple exostosis)

- many sessile, many pedunculated or mix of two

Osteochondromas MC seen

- Distal femur

- Proximal femur

- Pelvis

- Proximal Humerus

MC benign tumor of hands and feet → Enchondroma

- One of my differencials is giant cell tumor

- Never put down giant cell tumor as a DX in hands and feet unless you are

willing to bet you life on it

- Calcified cartilaginous matrix

- Multiple Enchondromas – Ollier’s disease

- Radiographic signs

- Expansile lesion

- Geographic lesion

- Thinning of cortices

- Calcified cartilaginous matrix

MC benign tumor of the skull → Osteoma

- Usually seen in frontal sinus

- View – Cadwell view

- Osteoma vs. sinusitis – with sinusitis you have fluid level in sinus

CHEST

99% of DX come off of PA chest

Lateral Chest used for localization of the problem

Part IV one condition – may force you to DX on lateral chest – Hietal Hernia

If you see heart and diaphragm on film – PA chest film

If you see outline of sternum – Lateral Chest

Heart shadows always point to left side.

Gastric bubble is always under left diaphragm – Called magenblase

2 lobes on left

3 lobes on right

Left Lung

- From apex of lung to cardiophrenic angle – left upper lobe

- From Cardiophrenic angle to costophrenic angle – left lower lobe (small amt)

Right lung

- From apex of lung down to bronchus – right upper lobe

- From bronchus to cardio phrenic angle – right middle lobe

- From cardiophrenic angle to costophrenic angle – right lower lobe (small amt)

6 steps

1. Check apexes side to side

2. Come down comparing side to side

3. Check bronchus are side to side

4. Check Cardiophrenic and costophrenic angles side to side

5. Check heart shadow

6. Check gastric air bubble

Detail of 6 steps

1. Check apexes side to side

-White density in apex of lung – 2 conditions

1. Pneumonia

2. Pancoast tumor

- Differenciate – does white density stay in and around clavicle or does it extend

well below the level of the clavicle

- Stay in and around clavicle – Pancoast Tumor

- Extends below clavicle – Pneumonia

2. Come down comparing side to side

3. Check bronchus area side to side

- If you see white density in bronchus area – 2 conditions

1. Pneumonia

2. Bronchogenic carcinoma

- Differenciate the two:

- If you see the outline of the lobe – due to fluid level seen with

pneumonia

- If you don’t see outline of lobe you cannot differenciate pneumonia from

bronchogenic carcinoma on x-ray; therefore go to history

- Typical History for pneumonia

- Get cough for 10 days (productive)

- Speutum is rusty brown color

- Usually have fever

- Also look at age

- Typical History for bronchogenic carcinoma

- Cough for about 1 month (non-productive cough)

- Afebrile

- Usually history of smoking for 20 – 30 years

4. Check cardiophrenic and costophrenic angles

- Obliteration or blurring of angles – silhoette sign- means we have a problem

5. Check heart shadow

- Cardiomegally – Can usually eyeball it

- If width of heart shadow is wider than ½ of chest cavity – cardiomegally

6. Check gastric air buble

- Usually seen beneath diaphragm

- If it is above diaphragm → hietal hernia

- Best view to see this on lateral view

If you see big round white densities in lung, cannonball lesions of Metastatic disease

When you see tiny white densities – 3 conditions

- miliary TB Snow Strom Appearance

- Pulmonary TB Snow Flurry Appearance

- Pneumocoidiosis Snow Flurry Appearance

Can you count them?

No – miliary TB

Yes – pulmonary TB vs. pneumocoidiosis

Differentiate the two by history

- If traveled to 3rd world country, work in prison or at a nursing home – Think TB

- Fever night sweats – Think TB

- Pneumocoidiosis – inhalation of dust particles – look at occupation of patient

Emphysema

4 radiographic signs

- bilateral loss of hilar markings

- horizontal ribs – barrel chest appearance

- Flattening of diaphragm

- Compression or narrowing of heart – called stove pipe heart

Atelectasis vs. Pneumothorax

When you see one lung dark and one lung field white – 2 conditions

1. Atelectasis

2. Pneumothorax

Either atelectasis on white side or pneumothorax on dark side

To differentiate, go to dark side

Ask – Do I see vascular markings?

Yes – Atelectasis

No – Pneumothorax

Sarcoidosis

- Usually seen in African Americans

- Get bilateral hilar lymphadonopathy

- “Potato nodes” – Part IV

- If you see angel wings – then sarcoidosis

SCOLIOSIS

Two basic types:

1. Congenital

2. Idiopathic

Congenital scoliosis is a result of congenital anomaly on the film. (ie. Most likely a hemivertebra)

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

- Structural – Scoliosis does not change based on postion

- Functional – Scoliosis will change based on postion

Name it by convexity of curve

Measure Scoliotic curve:

- Cobb Method (best way)

- Riser- Furguson

Monitoring Scoliosis

< 20° adjust and monitor

20° - 40° refer out for bracing

> 40° surgery

For Part IV anything over 20° you do not treat – refer out

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 larger curve.

Complications of scoliosis

- Cardiopulmonary problems

- Postural fatigue

- May cause early DJD due to altered weight bearing

Pattern for Part IV

1. Pick condition you know it is = 1st answer

2. When picking 2nd answer, do the following:

a. 1st look for aka of condition

b. Then look for radiographic sign associated with that condition

c. If none of above is there – pick differential






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