Part 4 Radiology

Sickle Cell Anemia in the skull

"Hair on End" appearance skull "H" shaped vertebra in the spine: -Collapse of Vasculature. (each vertebral body has to be "H" shaped)

Multiple myeloma in skull

"Rain Drop" Skull similar in size and shape

Non-Ossifying Fibroma

"Small fibrous tumor" that affects the "metaphysis of bones". Over 9 years of age Over 2 cm

Non ossifying fibroma

"Small fibrous tumor" that affects the metaphysis of the bone. Over 9 years of age **Age would be the main thing. Over 2 cm

Fibrous Cortical Defect

"Small fibrous tumor" that affects the: -Metaphysis of the bone Under 9 years of age (to differentiate w/ Non-ossyfing Fibroma) Under 2 cm *ABC could be your last choice if less than 9 ***DO NOT CONFUSE WITH ABC*

Avulsion Fx's

"Tear Drop Fx" -Avulsion of the anterior inferior aspect of the vertebral body from a *HYPEREXTENSION TRAUMA" -Associated with "Acute Anterior Cervical cord Syndrome" loss of motor, pain and temperature. M/c @ C2

DJD of the Hip

*Bilaterally Compare billaterally sup. lat jt. space

Neutral Lateral Cervical (4th step)

*Check for the front of the Vertebral Bodies Look for Syndesmophytes (Inflammatory Spurs) 1.Marginal Syndesmophytes: AS -Push up against the vertebral bodies and disc space. -Thin eggshell calcification around the disc space. 2.Non marginal: Reactive Arthritis or PA (If it's not pushed up into the vertebral spine)

Type 2 Salter Harris

*M/c fx of Salter Harris Through the growth center and Metaphysis A-Across **Thurston Holland Fragment**

Lytic Mets in skull

*Sweese Cheese Appearance" Small, medium, large densities. Difference in size holes

Lytic Mets

*Turns the bone darker in color, eats away pedicle of the bone. >40 yrs old; recent unexplained weight-loss; skeletal pain worse at night; cachexia; nothing palliative/provocative. Moth eaten or permeative pattern of destruction. *Eats away pedicle of bone, Owl Winking Sign. Can cause a pathological collapse (vertebra plana) "Swiss Cheese" Appearance in the skull. Lab: Alkaline Phosphatase (Increased) -Goes up when we are lying down bone) Special test: Bone scan (would come back HOT) -measures attempt to break down bone.

Pagets in the skull

-Cortical Thickening -Osteoporosis Circumscripta (one large density seen with Paget's; not coming in boards) -"Spiculated" periosteal reaction -No Hair on ends

Benign Bone Tumors X rays

-Encapsulated (wether fx or not) -Short Zone of transition -Geographic Lesion -Incidental Findings -No labs -Refer to orthopedists b/c cortex gets thin then you can get a fx.

Hemivertebra

-Failure of development of a lateral ossification. -Isolated Wedge vertebra causes a "Structural Scoliosis" -Associated with "Scrambled Spine Appearance" -Structural scoliosis (Adam's Flexion -forward scoliosis does NOT go away) -Case Management: Adjusting *Own vertebral body, own vertebral space, does NOT cross midline. *Could also be seen in a "Lateral View" *Non-segmented: -crosses midline. -It has a large side. -in which you have 2 pedicles in one side. -PEDICLE DUPLICATION SIGN. DO NOT PICK CONGENITAL FUSION OF RIB.

Avulsion fracture

-Jagged and displaced An avulsion fracture is an injury to the bone in a location where a tendon or ligament attaches to the bone. When an avulsion fracture occurs, the tendon or ligament pulls off a piece of the bone. Avulsion fractures can occur anywhere in the body, but they are more common in a few specific locations.

DJD

-Lipping and spurring (Osteophytes-non inflammatory spurs) -Decrease disc space -Sclerosis of Endplates (Eburnation: sclerosis of endplates "Whitening") -Usually stiffens with rest and improves with activity. -Complications include spinal stenosis and IVF encroachment. -You never rule in/rule out until you check the DISC SPACE. DJD affecting the vertebral bodies: -Discogenic Spondylosis

The skull and other parts as well

-Paget's -Lytic Mets -MM -Acromegaly -Sickle Cell Anemia -Thalassemia -Hyperparathyroidism -Osteopetrosis

Malignant Bone Tumors

-Skeletal pain worse at night. -Unexplained weight loss -Cachexia (weakness and wasting of the body due to severe chronic illness.) -Long zone of transmission -Non encapsulated -Permeative patten of destruction -Refer to Oncologist

Spinouses

-Spina Bifida -Fx's -Missing (due to surgery; Laminectomy)

Neutral Lateral Cervical (1st step)

1. Check for Soft tissue in the front of the Spine Retropharyngeal space=7mm Retrolaryngeal Space=14mm Retrotracheal Spac= 21/22mm normal If Soft tissue is larger than *Vertebral Body* this indicates *Soft Tissue Swelling*. Soft tissue Swelling due to: Trauma, Infection or Malignancy.

A-P Pelvis

1.Check the lower 1/3 of the SI joints. *2.Check the inner portion of the pelvic for: -Paget's, Fx, Protusi Acetabuli 3.Check the Outer portion of the pelvic inlet. While doing so, draw a line from the outer portion of the ilium to the outer portion of the ischium. Make sure some portion of the femoral is inside of this line. If not, -Congenital Hip Dysplasia/Hip dislocation 4.Compare side to side Ilium, Ischium, and Pubis. **** 5. Compare side to side femoral head and acetabulum. 6.Compare side-to side femoral neck and shaft. 7. Check the soft tissue inside the pelvic inlet. -Conditions of the Hip: Paget's,Protusi Acetabuli, Congenital Hip Dysplasia, Rider's Bone, Fx's, Slipped Capita Femoral Epiphysis, Legg Carve Perthes.

A-P Knee X Ray

1.Check to see if the tibial eminences are jammed into the fossa if so, "Decrease Jt. space". 2/3. Check the medial/lateral joint spaces. Conditions: DJD: Decrease medial jt. space, Lateral side is preserved. Medial side is the most weight bearing. If severe, you have medial/lateral and severe **SCLEROSIS**. (really whitish) RA: Decrease Medial/Lateral Joint space w/ minimal sclerosis. 4.Check the Periosteum 5.Check the Cortex 6.Check the Medulla 7.Check the Growth Centers 8.Check the Soft tissue Conditions to see: 1.Osteochondritis Dessicans 2.Pelligrini Steida 3.Calcium Pyrophosphate Dihydrate Crystal Deposition Disease 4.Neurogenic arthropathy (Charcott's Joint) 5.Osgood's Schlatter's

Parallel/Laminated include

1.Ewing's Sarcoma 2.Infection 3.Trauma

Whiter Color Indicates

1.Hodgkin's lymphoma 2.Blastic Mets 3.Paget's These all cause the bone whiter in color

Spiculated/Sunburst/Radiating

1.Osteosarcoma 2.Chondrosarcoma and Fibrosarcoma (Do not have to differentiate in the test.)

Step 1: Periosteal reaction, 2 types we are concerned with:

1.Parallel 2.Spiculated *Periosteal rxn: New bone growth.

Should see vascular markings (tiny white lines) on each side of the bronchus. If lost on one side, two possibilites:

1.Pneumothorax 2.Atelectasis

Fractures of the femur

1.Subcapital 2.Midcervical 3.Basicervical*T 4.Intertrochanteirc 5.Trochanteric 6.Subtrochanteric

Radiology Testing Info

10 stations w/ 4 minute per station. Each station has a case Hx, which should be read first. Proceed to scan the answers to the questions that are being asked, it shows were to focus. After you read the case hx, and scan all the answers then proceed to look up at the view box. There would be anywhere from 2-5 X-rays per station.

Ewings Sarcoma

10-25 yr. old M/c found in diaphysis of long bones. Permeative lesion that causes a multi-parallel onion skin (laminated) type of periosteal reaction. Bone expansion Codman's Triangle* Saucerization Special Test: Bone Scan (Hot)-Laying down bone. Increase Alkaline Phosphatase Refer: Oncologist (Painful cancer) If in Organs, Painless cancer. A true permeative process of bone, or moth-eaten appearance in bone, describes multiple small endosteal lucent lesions or holes, often with poorly defined margins, with sparing of the cortex. It is a bone marrow process.

Osteoblastoma

10-30 yo M/c benign bone tumor to affect the: -Neural Arch (Bone expansion of the neural arch) -Missing pedicles; Lytic mets does not cause bone expansion. ABC: less 20 GCT:20-40

Osteochondritis Dessicans

16-25+/- , athletes, knee locks out upon "EXTENSION". Associated w/ Wilson's Sign. Best Seen on Tunnel's View. Radiographic signs: -Crescent sign -Radiolucent Half-moon shape -Osteochondral body -Osteochondral fragment Joint mouse Also an AVN. **Lateral aspect of the medial femoral condyle.** **NO DECREASE MED/LAT JT.Space. Refer to orthopedist. 8 moths-2 yrs. AVN, caused by trauma, Refer to orthopedic Surgeon.

Left side of chest

2 lobes: Left upper lobe: -Apex to Cardiophrenic angle Left lower lobe: -Cardiophrenic angle to below **We should see vascular markings on both sides of the bronchus.**

Giant Cell Tumor

20-40 yo Epyphiseal/Metaphyseal *Look at age to differentiate from Chondroblastoma. 20% of the time Quasimalignant Associated w/ the -Soap bubble appearance (Saponaceous)

.Right side of Chest:

3 lobes Right upper lobe: Apex to bronchus (5th space) Right middle lobe: "Bronchus to Cadriophrenic angle* Right lower lobe: -Everything below cardiophrenic angle **We should see vascular markings on both sides of the bronchus.**

Hyperparathyroidism

30-50 yo Over activity of Parathyroid gland causes calcium build up in the blood and phosphorus down. Increased Alkaline phosphatase Ca+ high, Phosphorus down "Salt and Pepper skull" "Rugger Jersey" spine Renal Calculi, "Brown Tumors" (central geographic osteopenia in bones) Systemic/metabolic -every single bone has to be involved.

Elbow and Forearm X-ray

50% of the time you fracture your Radius you fracture your Ulna. Fat Pads -"Sail Sign" indicates inflammation due infection, trauma, Inflammatory Arthrotide Anterior Fat Pad normally pushed against the bone. Sail Sign- pushed away from the bone. Posterior Fat Pad- normally not seen. Fractures in this view: Nightstick Fx: -Fx of the Proximal ulna Monteggia Fx: -Fx Proximal Una with Radial Head displacement Galeazzi Fx: -Fx of the Distal 1/3 of the radius with dislocation of the "Distal Ulna" Chissel: -Vertical Radiolucency through radial head. Greenstick/Hickory Stick: -Incomplete fx in children (One side of the cortex is affected, not the other side; m/c at the radius) For board purposes the same: Impaction Fx: -Bone fragments driven into one another. Torus/Buckling Fx: -Incomplete Fx, one side of the cortex is affected.

Hip Dislocation

A traumatic hip dislocation occurs when the head of the thighbone (femur) is forced out of its socket in the hip bone (pelvis). It typically takes a major force to dislocate the hip. Symptoms of a hip replacement dislocation include: Intense pain in the hip and groin area. Hearing a popping sound. Inability to move the leg of the replaced hip. Difficulty or inability to walk. The affected leg becomes shorter than the other leg. In hip dislocation, the femoral head is dislodged from this socket. Posterior dislocation is the most prevalent, in which the femoral head lies posterior and superior to the acetabulum. This is most common when the femur is adducted and internally rotated.

Leg Calve Perthe's

AVN of the Femoral Head M/c found in in boys 4-9 yr old M/c cause- trauma Radiographic signs: -Fragmentation of the femoral head (Crescent sign) -Flattening of the femoral head -Increase white density of the femoral head (Snow capped appearance) -Increased Joint Space Healed leg calve perthe's: -Mushroom cap appearnace -No more fragmentation, increase joint space, etc. -Sagging Rope Sign (X-ray Finding) Case Management: -No labs, Special Test: MRI/Bone Scan -Stop any athletic activities -Refer to Orthopedist- "A Brace" If left untx: Can lead to DJD or Possible Hip replacement.

Bone infarct X ray

AVN/Osteonecrosis to the metaphysis of the bone (blood supply) Seen in: Case Hx** -Deep sea diver -Flight Attendant Bone infarct refers to ischemic death of the cellular elements of the bone and marrow. (AVN/Osteonecrosis)

Infection (Infective Arthritis)

Aka "Infective Arthritis", "Infective Spondylosis", "Discitis", "Osteomyelitis", "Pott's Dz", "Septic Arthritis" -Only condition that alters disc space in size and color, eat away the surrounding end plate.* -Pt. presents with a fever, chills, possible hx of trauma, recent surgery and a warm, tender, swollen joint. -Refer out; Chest X-ray; Sputum culture; *WBC count*, ESR, CRP. -Case management: ER, IV antibiotics.

2.Osteitis Condensans Ilia (A-P Lumbopelvic)

Aka "Osteitis Triangularis -Multiparous females, 20-40 yrs old, Female-Back pain, NOT fused SI's. -May have notches -Bilateral/Symmetric triangular sclerotic areas on the lower half of the ilium. -Joint Space is "Spared"; Not altered; does NOT affect the joint) -Self resolving, no labs. -Case management: Trochanteric Belt For stability. -*Bilateral Whitening of Iliac Side but NOT the sacral side.

Uterine Fibroid

Also known "Fibroid Cyst/Leiomyoma" (m/c benign tumor of the female) Tumor of smooth muscle. Location: Somewhere midline horizontally from the femoral heads. (Not on top of the Pubic Symphysis) Color: White in Color

Ankylosis Spondylitis (AS)

Also known as " Marie Strumpell's Dz" -Vinet 22yr. old part 4 -Males; 15-35 yo; LBP w/ morning stiffness -Autoimmune condition, Rheumatologist (Corticosteroids/Non Antiflammatory) -Associated w/ Iritis/Uveitis -Ortho's: Chest Expansion, Forester's Bowstring's and Lewin Supine. Radiographic findings: -SI joints: bilateral SI joint fusion (ghost joints) -Spine: Shiny Corner Sign (early); bilateral marginal syndesmophytes with thin eggshell calcification around the disc; squaring of the vertebral bodies; Bamboo spine, Dagger Sign, Trolley Track Sign, Poker Spine, Anderson Lesion, Carrot Stick Fx. Labs: HLA B27 (+), ESR (+) Case management: co-treat w/ a Rheumatologist (we can adjust.)

Butterfly vertebra

Also known as " Receded Cortical Endplates"; "Indented Cortical Margin". - -Failure of the center of the Vertebral body to ossify properly. **Never creates Scoliosis **Sagital Cleft Defect (Cleft: Split) **Increase Intrapedicular Distance Receded:Move away/Indented:Divided

Neurogenic Arthropathy

Also known as "Charcott's Joint" Secondary to impaired sensory function in joints. Seen w/ Diabetes, or anything that destroys neurosensory; Neurosyphylis (Tertiary Stage), Leprosy, Alcoholic Neuropathy, Corticosteroid Usage, Tabes Dorsalis, Syringomyelia. 6 D's m/c in weight bearing joints: Distention (The state of being distended, enlarged, swollen from internal pressure.) Density of subchondral sclerosis Debris within the joint(scattered pieces of waste) Dislocation Disorganization Destruction of bone M/c in: Hip, Knee, Shoulder or somewhere in a large joint. Color Motive: Bone Film (White bone, blackened soft tissue)** Hypermobile painless Joint.

Kidney Stones X-rays

Also known as "Nephrolisthiasis" Location: L1,L2 (Start at your SI joint to L1,L2) Color: Solid White Color (made of Calcium) Referral is to the flank. IVP study KUP study -X rays for kidneys, ureter, bladder. An intravenous pyelogram (IVP) is an x-ray examination of the kidneys, ureters and urinary bladder that uses iodinated contrast material injected into veins. An x-ray (radiograph) is a noninvasive medical test that helps physicians diagnose and treat medical conditions.

Paget's X-rays

Also known as "Osteitis Deformans" Males >50 yo It **Starts in the cortex** Causes Cortical thickening called "Picture Frame Vertebra" in spine; increase bone density; coarsened trabeculae, can cause basilar invagination. Labs: Increase Alkaline Phosphatase, Urinary Hydroxyproline. Special Test: Bone Scan (Hot) Cotton Whool, Osteoporosis Circumscripta, Brim Sign, Blade of grass appearance, Sheave of wheat, or sheave of grain, candle flame.

Multiple Myeloma X-ray

Also known as "Plasma Cell Sarcoma" Neck Pain >50 y.o., weight loss, anemia, cachexia, bone pain worse at night, nothing palliative/provocative. M/c primary malignancy of bone. Malignant proliferation of plasma cells infiltrating bone marrow. Multiple dark densities that are similar in size ("punched out lesions") in extremities. Can cause pathological collapse (Vertebra plana) -Wafer thin, Pancake vertebra, Coin on end vertebra, Silver Dollar vertebra. Associated w/ Rain Drop Skull Labs: Reversal AG Ratio, M-Spike Immunoelectrophoresis, Bence Jones Proteinurea, ESR (non specific inflammation) Aplastic Anemia also called "Normochromic/Normocytic Anemia". Special Test: Bone Scan (Cold) Aka "Scintigraphy" Aka "Radionucleotide" Refer to Oncologist

Scleroderma

Also known as "Progressive Systemic Sclerosis" Females, 30-50 yo. mostly in the hands. Associated with "erosions of the distal tufts of the phalanges" called -Autoamputation -Osteoacrolysis w/ no joint destruction, preserved joint space. Associated with CREST syndrome: C-Calcinosis Cutis R-Raynards Phenomenom E-Esophageal Dysfunction (GERD, Gastric Reflex) S-Sclerodectaly (Scleroderma of hands) T-Talengectasis Labs: FANA/ANA +RA Latex (30%

Limbus Bone

Also known as "Un-united Epiphysis" -Smooth and in place.

Jones Fracture

Also known as Dancer's Fx Peroneous brevis, Plantar flexion, Eversion

March Fracture

Also known as Stress Fx Fracture of 2,3, 4th metatarsal

Scheurman's

Also known as: -Avascular Necrosis -Ischemic Necrosis -Aseptic Necrosis -Osteonecrosis -Subchondral Necrosis -Osteochondrosis of the spine M/c seen between ages 10-16 Case Hx: rounded shoulders, back pain**, increased kyphosis. Radiographic Signs: -*Multiple endplate irregularities of 3 or more continuous vertebrae. -Slight loss of anterior body height of one or more vertebra (10-15%) -Increased Kyphosis -DESTRUCTION is similar from END PLATE to END PLATE. Case Management: -Thoracolumbar brace; Strengthen the erectors & Stretch the Pecs; self resolving (8 months-2 years) , kinesio Tape, Quit athletic or weight bearing activities. -Could have them swimming(non-weight bearing) Can lead to permanent postural deformity and early DJD. Special Tests: Bone Scan or MRI(Best) All AVN's are due to TRAUMA. -No labs for AVN. Multiple Schmorl's nodes

Neutral Lateral Cervical (6th Step)

Approximate the DENS for height, alignment and color. Height: -Dens is similar in size to C2 vertebral body. *Majority of the Dens should be below the base of the occiput. -If not, Basilar Invagination/Impression -Mcgregor's line, Chamberlain's Alignment: -Dens should lined up w/ the C2 body. -If displaced: Fx Color: *Only check color if ADI it's not seen. -If DENS is there up the atlas it will appear WHITER than a C2 body.

What is your first impression?

Are you DISTRACTED? If you are Distracted: Is it Congenital, Acquired or NOT sure? Congenital Anomaly Rule: Once you chose the congenital anomaly (for sure) on the film, do not worry about "alterations of color" from Paget's, Malignancies, Infections. Do NOT worry about subtle Fx's/Dislocations. Stress Hypertrophy of bone (Makes bone whiter) Subtle-so delicate or precise as to be difficult to analyze or describe. Acquired:Anything that causes inflammation and affects the spine. Ex: Trauma, AS, PA, Reiter's, etc. NO GOUT, if inflammatory but does not affect the spine.

Rider's Bone (Hamstring)

Avulsion of the Ischial Tuberosity Attachment of hamstrings muscle. M/c found in horseback riders, cheerleaders, hurdlers.

Protusion of Acetabuli

Axial migration of the femoral head with uniform loss of joint space. Bilaterally most often occurs with "Rheumatoid Arthritis" Also seen with anything that softens or weakens the bone. Obliteration of Kholers's Teardrop. Line of menstruation: Kholer's Line LAB: RA Latex, Rheumatoid Factor

1.AS (A-P Lumbopelvic view)

Bilateral fusion of the SI joints (Bilateral Sacroilitis, Enteropathic Arthritis) Age:15-35 yrs old.-Back pain, morning stiffness. X-rays findings: -If its NOT bilateral its NOT AS. -Early Stage: Bilateral Erosions + sclerosis w/ pseudo joint whitening . -Late Stage: Bilateral Fusion of the SI joint "Ghost Joints" or "Star sign". **T-Pelvic inlet of "Animal Ears"; Micky Mouse Ears" -focus on SI joints.

Step 3

Bilateral whitening and enlargement on each side of bronchus: **Sarcoidosis** -Shape of Potato Nodes -Angel Wings -M/c found in African American, remember they will show RACE. **Hodgkins** Unilateral Hilar lymphadenopathy: -Caucasian Males (White) -Enlarged, Potato node, Angel wing **Pulmonary Mets** -Bilateral -Well-circumscribed cannonball lesions. -Large circular white densities/lesions. -Could also happen in a kid, even if its rare. **Tuberculosis** -Tiny white spots densities throughout the lung fields. -+Mantoux test -Tine Test -PPD Test (positive purified protein derivative test -Most definite: Sputum culture -Case Hx: -Low grade fever. Night sweats Case management: Notify the authorities

Cervical rib

Bone articulating with bone.

Fracture of Dens

Bone displaced from itself. "Appears Joggy" Brace the neck, stabilize collar called "Philadelphia Collar" Refer to Orthopedic Surgeon.

Inverted Napoleon Hat Sign aka's

Bowling of Brailsford Aka "Gendarme Hat/Cap"

Slipped Capital Femoral Epiphysis

Boys 10-16 yr. old Salter Harris Type 1 Fx Femoral Head slides inferior and medial/femoral neck slides superior and lateral Lines: Klein's line, Skinner's, Shenton's Case management: Refer to Orthopedist

Sessile Osteochondroma

Broad based exostosis

Calcium Pyrophosphate Dihydrate Crystal Deposition

CPPD/Pseudogout/ Called "Chondrocalcinosis" when affecting cartilage. Fine linear calcification parallel to the articular cortex within the joint space. Fine linear crystals within the knee jt. w/ NO bone destruction. **Be able to differentiate with Synoviochondrometaplasia.**

Myositis Ossificans

Calcification of the "Muscle belly" -M/c seen in Biceps/Quadriceps See soft tissue film -Soft tissue is white/Bone white Makes you differentiate with SYNOVIOCHONDROMETAPLASIA -Popcorn, around and in Joints.

Pelligrini Steida

Calcification of the MCL aka "Tibial Collateral Ligament" Radiographic sign: -Whisp of smoke appearance

Staghorn Calculi

Calcification of the whole renal calyx. Not just one kidney stone. Many and bigger.

Phleboliths

Calcifications within veins, Asymptomatic (Outside Bladder) Top of bottom half, OUTSIDE bladder. Even if you get some in bladder and some outside you still have to call them like that.

Calcinosis Cutis

Calcinosis cutis (or cutaneous calcification) is a type of calcinosis wherein calcium deposits form in the skin. A variety of factors can result in this condition. The most common source is dystrophic calcification, which occurs in soft tissue as a response to injury.

P-A Hand View

Can ask anything but m/c are "Arthritides". 1.Check the MCP's (M/c condition RA) 2.Check the PIP's (PA,OA, RA) 3. Check the DIP's (PA, OA, NEVER HAVE RA) Then check the periosteum, cortex, medulla.

Internal Rotation Shoulder View

Can see greater tubercle which is the attachment for the Supraspinatus Tendon.

Trauma

Case Hx or Signs of New Trauma on film. (Avulsion Fx, Facets Dislocations) Step Defect: Superior endplate fx's and slides forward. Line of Double Density aka "Zone of Impaction" Aka "Line of Condensation", more sclerotic. (Step deformity is a skeletal deformity in which 2 adjacent bones which should be aligned with each other are displaced and are at different levels - resembling a step of a staircase. Examples: Step deformity of spine. two adjacent vertebra are at different levels.)

APOM (Step 5)

Check Para-odontoid spaces. (Not that important.) Space between Lat mass and Dens. If unequal--> Jefferson's Fx.

APLC (Step 4)

Check SP's. Missing: -Surgery -Congenital -Lytic mets -Agenesis. Spina Bifida:vertical radiolucency through the midline of the spinous, "smooth cortical margins"

Step 7 (A-P Lumbopelvic)

Check Soft tissue from the ribs down to the iliac crest.

Neutral Cervical Spine (Step 12)

Check Spinolaminar lines and spinouses. Absence of Spinolaminar line= *SPINA BIFIDA* Spina Bifida of C1= Spondyloschisis Defficient in B9 Follic Acid Signs of surgery: If the spinouses are cut away we have a laminectomy. If the Spinouses are eating away "tooth marks"=LYTIC METS IF missing=Agenesis of SP's Fx's: Bone displaced from itself. Avulsion C6, C7, T1 = Klay Shoveler's (MOI Hyperflexion trauma) Double spinous sign seen on Lateral View only used w/ SP Frature.

Step 1 (A-P Lumbopelvic View)

Check for lower 1/3 of the SI joints for (3) possibilities:

Neutral Lateral Cervical (10th Step)

Check for pedicles of C2 for Fx's. Vertical Radiolucency= Fx *Hangman's Fx MOI:Hyperextension Trauma Spondylolisthesis Type 4-Traumatic NOT ISTHMIC Would they make us choose? between"Hangman's fracture" is the colloquial name given to a fracture of both pedicles or pars interarticularis of the axis vertebra (C2).

APOM (Step 7)

Check for the Posterior Arch of Atlas and the SP's of C2 and C3 for Spina bifida. Spondyloschisis (C1)

Step 4 (A-P Lumbopelvic)

Check for the Sacrum for: -Alterations in color or shape -Spina bifida -Knife Clasp Deformity

APOM (Step 6)

Check lateral masses for overhanging. -will indicate *Jefferson's burst Fx. -associated with "Russ sign", refer to Orthopedic Surgeon.

Step 5 (A-P Lumbopelvic)

Check the "Square Block-head system" from the bottom up. (Disc spaces while coming up)

Neutral Lateral Cervical (2nd step)

Check the ADI space. -Normal ADI in adults: 3mm -Normal ADI in children: 5 mm Increased ADI is caused by: Transverse ligamentous Laxity or if congenital is Down's Syndrome. If the ADI is similar in width to the Anterior Tubercle it equals an increase/abnormal ADI. Worse case scenario: Cord Compression.

APLC (Step3)

Check the DISC SPACES and UNCINATES for "Uncinate Arthrosis". Joints of Lushka; Covertebral joints Uncinate Arthrosis is the #1 cause of IVF Encroachment. Cervical Oblique-IVF encroachment. Lat Cervical- A dark line (similar to Mach effect) that appears like a Fx. (Sclerosis in a "half moon shape") -Hemispherical Spondylosclerosis

Non-union of the DENS (Os Odontoidium)

Check the Dens for Radiolucent line. 80% usually in place, smooth cortical margins around non-united pieces. (Both pieces) Can occur Hypertrophy of the Anterior Tubercle, Hyperspinous of C2. (Bigger to stabilize it)

Neutral Lateral Cervical (Step 8)

Check the Disc Spaces and Endplates -DJD -DJD of spine: Discogenic Spondylosis -sclerosis of end plates Vacuum phenomenon: is gas (black); Aka "Knutson Phenomenom", "Phantom Disc", IVOC Intervertebral Osteochondrosis. -Infection (Infective Arthritis, Discitis, Infective Spondylitis, Septic Athritis, Osteomyelitis, Pott's Dz.) **BLASTIC does NOT AFFECT THE DISC SPACE/JOINTS , IT AFECTS THE MEDULLA.

Step 5 (Extremities)

Check the Growth Centers -If one is open, there should all be open. -Growth centers of the Vertebral Bodies (Less than 12)

Step 6th (Extremities)

Check the Soft Tissue for: -Myositis Ossificans

Step 8 (A-P Lumbopelvic)

Check the Soft Tissue inside the pelvic inlet.

Lateral Lumbar Film (Step 1)

Check the Soft tissue in front of the vertebral bodies. **Abdominal Aorta** (L2, L3, L4-sits in front ) -M/c location of an Aortic Aneurysm: L2,L3,L4. -Normal abdominal aorta can measure up to 3.8 cm if calcified "Atherosclerosis". -If larger than 3.8 equals AAA. (*If its up to half of a vertebral body:Atherosclerosis, could adjust; Larger than a vertebral body-AAA) -Radiographic signs: Aortic Dilation *Curvilinear Calcification Fusiform Appearance Special Test: Doppler, Diagnostic US, Ultrasonography, CT(BEST ONE), ANGIOGRAM (MRA) Case management: Refer to cardiovascular specialist, NOT ER. Worst care scenario: Hypovolemic Shock due to rupture.

Lateral Cervical (5th step)

Check the base of the Dens for a Radiolucent line. Top of TP of C2: if you have a radiolucent line. Extension view lifts C1 Up. Four possibilities: 1.FX 2.Non-union 3.Agenesis 4.Mach Line

APOM (Step 3)

Check the base of the Dens for a radiolucent line. If present; 2 possibilities: 1. Fracture: Bone displaced from itself. Leaning or tilting- thin radiolucent line @ Base of Dens. 2. Non union of the Dens -Os Odontodium *Big & Thick Radiolucent Line *Apex smooth and usually in place.

APLC (Step 2)

Check the bodies for ALTERATIONS of COLOR & SHAPE. Do we have white, dark color? White-Pagets,Hodgkins, Blastics Dark -Lytic Mets/MM Only type of Fx: Pathological Fx's (Ant/Posterior) -MM/Lytic

Neutral Lateral Cervical (Step 7)

Check the bodies for alterations in color and shape.

Lateral Lumbar (Step 3)

Check the bodies for alterations of color and shape.

Step 2

Check the cortex. (4) things we are concerned with: 1.Thinning: Osteoporosis (Periosteal thin cortex, Gray bone/Soft tissue) 2.Thickening: Paget's 3.Interruption: Fracture or Non-union -Oblique Fx: Spiral fx due to trauma. -Transverse fx: usually indicates pathological fx. (Lytic mets, MM) could possibly be. IF pathological aka "Banana fracture" 4.Deformity of the cortex: Paget's or Fibrous Dysplasia Fibrous Dysplasia: deformity, bending/twisting of bone. Paget's: Deformity of Tibia: Saber Shin Tibia Deformity of Femur: "Shepherds Crook"

Lateral Lumbar (Step 4)

Check the disc spaces and endplates.

Lateral Lumbar (Step 2)

Check the front of the vertebral bodies

4rth step (Extremities)

Check the joint spaces.

A-P Foot

Check the joints. -MTP's -PIP's -DIP's Trace out the cortex of the bone for FX's. Check for AVN's. Fragmentation of the 2/3 metatarsal heads: -AVN: Freiberg's Dz Fracture of 2,3, 4th metatarsal: March Fx Aka "Stress Fx" *Board Purposes- Bony callus refers to a new fx DO NOT ADJUST Fx of the base of the 5th metatarsal -Jones/Dancer's Fx Plantar flexion, Eversion, Peroneus Brevis What happens in the feet can also happen in the hand. -RA -OA -PA -Gout could happen in both

Step 3 (Extremities)

Check the medulla Color: Whiter- Blastic Mets/Pagets/Hodgkins Lymphoma Darker-Lytic Mets/M.M./Benign Bone tumors Whitish- condition where every bone (Medulla/cortex) is involved- Systemic/Metabolic

Neutral Lateral Cervical (Step 9)

Check the posterior Arch of Atlas A.Missing: -Surgery: Cut away, staples, wires. -Malignancy: Eaten away by lytic mets. (*Teeth mark on bone; ex: eating an apple) -Agenesis: Megaspinous of C2, hypertrophy of Anterior tubercle B. Vertical Radiolucency: Fx vs. Non Union *Spinolaminar junction lined up* Fx-Bone displaced itself Non-union- it would be in placed. If spinolaminar junction don't lined up= Fracture because its displaced. Check for Posterior Ponticle

Lateral Lumbar (Step 5)

Check the posterior bodies, pedicles, facets and pars.

APLC (Step 6)

Check the soft tissue on each side of the spine. a.Carotid Artery Calcification b.Lymph node calcification Side of spine:Vascular vs Lymph node Calcification. Vascular: lines up in one straight line. Lymph: will NOT line up; all around

APLC (Step 5)

Check the tracheal air shadow for deviation. Could indicate (4) possibilities: 1.Soft tissue swelling or tumor 2.Pneumothorax: will push it away, black (gas) 3.Atelectasis: same side, will suck it. 4.Enlarged Thyroid (M/C REASON) *PA chest view to confirm Atelectasis (Collapse lung; air escapes) Pneumothorax

APOM View (Step 1)

Check to see if the Dens is present. There is NO such thing as a HYPOPLASTIC DENS. If not present: AGENESIS OF DENS.

Pneumothorax

Collapse of lung. Air gets trapped in the lung fields. Therefore, no vascular markings. Air=black (gas) **Check the tracheal air shadow for deviations.** (if too difficult) Tracheal shift away from lesion Unilateral darkening of the chest due to collapse of lung.

White Bone/Black Soft tissue

Color motive is BONE.

Agenesis of the Dens

Color of where the Dens should be is similar to the color of the C2 body. **NO ADI (It's Missing)

Bladder Calculi

Color: Solid white in color Location: Bottom half/Larger *Inside the Bladder.

Ureter Stones X rays

Color:White Location: Top Half in lateral (Femoral Head lines)

Step 2 A-P Lumbopelvic

Compare one ilium to the other for alterations of color and shape. Color Whiter: Whiter- Blastic Mets and Paget's (cortical thickening). Darker: Lytic Mets, M.M., or Benign Bone Tumors. Shape: Paget's, Fx's, Fibrous Dysplasia (P.F.F.)

Neutral Lateral Cervical (3rd Step)

Compare the Spinolaminar of C1 to C2 (Posterior body of C2 to Spinolaminar line, NOT spinous. If Atlas has moved anterior (w/o a break in the posterior arch); 4 possibilities: 1. Increase ADI 2.Fx of Dens 3. Non union of Dens (Os Odontodium) 4.Agenesis of Dens. If Atlas has moved posterior (without a break in the posterior arch ); 3 possibilities: 1.Fx of Dens 2.Non Union of Dens (Os Odontodium) 3.Agenesis of Dens

Type 5 Salter Harris

Compression of the growth center

Congenital Anomalies

Congenital Block -Two segments fused together from birth. -Failure of segmentation w/ a concave portion. (*If you can't tell from the front; check the facets; 2 facets fused; spinolaminar lines) -2 facets, 1 spinolaminar line. Associated w/ **WASP WAIST APPEARANCE (CONCAVE APPEARANCE), hypoplastic disc "Remnent Disc", "Rudementary Disc Space".** Acquired -separate spinolaminar line, NOT CONCAVE APPEARANCE, Buldge; Acquired fusion.

Pedicle Agenesis

Contralateral Pedicle Hypertrophy and Sclerosis. (Compare w/ one above and below) Missing pedicle *OBVIOUSLY WHITER!!!

Thalassemia

Cooley's Anemia; Mediterranean Anemia Hereditary disorder of hemoglobin synthesis (microcytic hypo-chromic anemia) *Erlenmeyer flask deformity -Widened epiphysis "Hair on end" appearance in skull.

Paget's

Cortical thickening, enlargement, deformity (Whiter, BIGGER!!!)

PA (Psoriatic Arthritis)

DIP's, Distribution pattern, Increase joint space, & Darker (Bigger and Darker) Not confuse with OA, (whiter smaller) Males, 20-50; silver scaly lesions on extensors, pitted nails, cocktail sausage digits (Not seen in X-ray, seen in person) -Increase jt. space -Periarticular erosions -MOUSE EAR DEFORMITY -Pencil in cup deformity -Ray sign Lab: +HLA B27 -RA Latex Balancing POGOGA (Pencil in cup) Periarticular EROSIONS (PA) -not confuse with periarticular/juxtarticular osteoporosis of RA.

Hyperostosis/ Candle Wax Drippings

DISH Males >40 with Neck stiffness or pain on swallowing. Calcification of the ALL Radiographic findings: -Flowing hyperostosis (Anterior bridging: when the hyperostosis fuses together) -Candle Wax drippings -3 or more continuous segments involved. -Disc Space preserved*** Associated w/ Diabetes Can cause "Ossification of the PLL" No true labs for DISH. Could chose the one's for Diabetes. -Fasting Blood Glucose -Glucose Tolerance Test -HBA 1c (Glycosolated Hemoglobin) -to monitor it. Case management: we could adjust.

OA (Osteoarthritis)

DJD Decrease joint space with sclerosis -Whiter in the middle of the joint space. (Smaller/Whiter) -Also, have a distribution pattern. (Majority of joints.) -NOT INFLAMMATORY: so no ulnar or fibular deviation.

Lipping and Spurring refers to

DJD or Infection

Type 3 Spondylolisthesis*T

Degenerative (DJD of facets) aka Non-Spondylolitic Spondylolisis" (Facets would be whiter)

Type 1 Spondylolisthesis

Dysplastic (Congenital Anomaly) (Does NOT come often, elongated pedicles)

Knife Clasp Deformity

Elongation of the SP of L5 going into the spina bifida.

Acromegaly

Enlarged skull, hands and feet. Enlarged Sella Turcica Pituitary Tumor** Refer to endocrinologist. Lab: Somatropin growth hormone FYI: The branch of physiology and medicine concerned with endocrine glands and hormones.

Type 1 Salter Harris

Epiphysis slides along Metaphysis

Shoulder Views

External Internal Baby Arm 1.Trace the clavicle from lateral to medial and back checking for Fx's. 2.Draw a horizon line through the middle of the distal end of the clavicle. Check to see if the acromion falls well below the clavicle, if so: -AC separation, Take X-rays w/ or w/o weights. 3.Go to the coracoid process, slide out laterally to find the top of the glenoid fossa. Draw a horizontal across at the top of the fossa. Check to see if the humeral head falls 25% or more below this line, if so Glenohumaral Dislocation. -2 ortho's: Apprehension/ Dugas test -2 X-ray Signs of a chronic GH dislocation: 1.Hatchet's (Aka "Hill's Sach Deformity"; roughening or erosion of Humeral Head) 2. Bankart Lesion: Avulsion of the inferior border of the glenoid fossa. 4.Trace out the humeral head, neck and shaft. -Fx's, Paget's, Cortical thickening, etc. 5.Check the surrounding soft tissue. -HADD (Hydroxy Apatite Deposition Disease): generalized calcification within the shoulder, it could be Humerus, Acromion, etc. **See example given: Clock -12 : Calcification of Subacromial bursa -2/10: Supraspinatus Tendon calcification -3/9: Calcification of the subdeltoid bursa (If is there and below the greater tuberosity, so it cannot be calcification of supraspinatus. **Do NOT confuse any w/ bursitis/tendonitis, can't see them in X-rays** 6.Check the Glenoid fossa for fractures. 7.From the top-down, check the scapula and ribs.

affects 2 metaphysis of the bone

Fibrous cortical defect (under 9) Non-Ossifying Fibroma (over 9) Typically wont make you choose them (can pick 2) *Example from test: -Distal Tibia -Proximal Tibia

Dark bone/Dark Soft tissue

Film is "Overpenetrated". (Don't worry about what you can't see) Flexion-ADI

White bone/White Soft tissue equals?

Film is "under-penetrating". Motive- Film is taking for Soft Tissue Lumbar spine soft tissue m/c: Abdominal Aorta* (AAA; "Curvilinear line")

Step 3 (A-P Lumbopelvic)

Find L4/T12. Count Down from T12 and check for lumbarization or sacralization. Transitional Segments: Sacralization: L5 TP's may fuse or form joints with the sacrum. (Fused/Articulating) Lumbarization: 6 Lumbars (1st sacral segment appears like a lumbar segment)

APOM (Step 2)

Find structures creating Mach (Shadows) lines: -Arches of Atlas -Occiput -Teeth

APLC View (Step1)

Find the: T1 TP's: Ears UP C7 TP's: Ears Down. Check C7 TP's for Cervical Ribs or elongated TP's. (Longer than T1 TP's.) Hallstead/Adsons Test or other TOS TEST. FYI: A cervical rib in humans is an extra rib which arises from the seventh cervical vertebra. Sometimes known as "neck ribs", their presence is a congenital abnormality located above the normal first rib. A cervical rib is estimated to occur in 0.2% (1 in 500 people) to 0.5% of the population.

Non-marginal syndesmophytes

Floats out into the soft tissue. Does NOT have to be bilateral. AS have to be bilateral. *Reactive Arthritis/ Reiter's Dz* 20-30 y.o.; -Conjunctivitis, Urethritis, Arthritis, -Ulcers/blisters on feet/hands -Apthous stomatitis -Calcaneal Spur Caused by "Chlamydia" Lab: HLAb 27(+) Psoriatic Arthritis Males 20-50, silver scary lesions (red arythmatous flaky lesions) on EXTENSORS, Pitted Nails, Cocktail Sausage Digits, Ray sign, Atlantoaxial instability. Lab: HLAB 27 (+)

Colle's Fx

Fx of distal radius with "posterior" displacement of the distal fragment. Posterior: back of the hand. Associated with Dinner Fork/Silver Fork Deformity. MOI: Hyperextension Trauma

Bennett's Fx

Fx of the 1st metacarpal

Boxer's Fx

Fx of the 2nd/3rd metacarpal

Bar room Fx

Fx of the 4th/5th metacarpal

Pott's Fracture

Fx of the Distal fibula by itself

Smith's Fx

Fx of the distal radius w/ "Anterior displacement of the distal fragment" Associated with "Spade Deformity". MOI: Hyperflexion trauma

Bimalleolar Fracture

Fx through the distal Fibula & distal Tibia

Step 6 (Check the ribs)

Fx's: M/c conditions in the ribs. Lytic Mets: M/c malignant tumor in the ribs. M/c benign tumor in the ribs: Fibrous Dysplasia

2 benign tumors that affect the epiphysis

GCT Chondroblastoma

Step 3

Go to the area of the bronchi: -Unilateral whitening and enlargement; two possibilities: 1.Pneumonia -It has to have shape. (Line Straight) -No shape, have to go to case hx. -Febrile, productive couch. (10 days) Recent surgery or hospitalization. 2.Bronchogenic Carcinoma -Case Hx: -No fever (Afebrile) -Non-productiv cough (approx 30 days) -Smoking 20-30 years

Meyerdings Grading System

Grade 1: 1-25% slippage Grade 2: 26-50% slippage Grade 3: 51-75% slippage Grade 4: 76-100% slippage 100% slippage & drops on segment below. Grade 5- Spondyloptosis

Osteoporosis

Grey bone/ Grey Soft Tissue with pencil thin cortices of the vertebral bodies. *NEVER CAUSES A DECREASE IN POSTERIOR BODY HEIGHT.

Lytic Mets in skull

Has a "swiss cheese" appearance in the skull.***

Gastric Air bubble should be below diaphragm, if no

Hiatal Hernia Pr. presents with gas, heartburn, and indigestion (dyspepsia). Tests: X-rays Upper GI series Adjusting

If IVF smaller:

IVF encroachment Aka "Foraminal Stenosis" 1.Pinchy from anterior boundary: Uncinate Arthrosis 2.Pinchy from Posterior boundary: Facet Arthrosis If you have both: HOURGLASS FORAMEN (pinching from the front and back) IVF Larger: 1.Neurofibromatosis: Tumor causes "Posterior Body Scalloping" -Dumbell Shaped IVF -Caffe Au Laut Spots Coasts of California. 2.Agenesis of Pedicle DO NOT put OCCIPITALIZATION on an oblique view; it confuses you but the C1 is NOT attached; need more images to confirm.

Every station you will do as follows:

Identify the view(s). Ask yourself TWO Motive Questions: 1.What is the office motive? -Why did the Dr. take this view? Ex: Flexion/Extension (Ligament Laxcity); IVF's (Cervical Obliques); Ulnar Deviation (Scaphoid/Lunate). 2.What is the color motive? -Normal Colors -Gas & Fat are Black. -Muscle, Water and Soft Tissue are Gray. -Bone and Metal are White. Normal bone density colors in the X-ray: White-Bone/Grey-Soft Tissue/Black-Gas

Baby Arm View

If at your station, rule out: -Rule out Fx's, Dislocations and Separations (AC)

Check the heart shadow

If its larger than half of the chest: -Cardiomegaly -R sided Heart failure (CHF)

Fibrous Dysplasia

If the overall color of the medulla is similar to the adjacent soft tissue. Physiologic resorption of normal bone replaced by fibrous tissue. Causes deformity: -Saber Shin Tibia -Sheppard's Crook "Ground Glass appearance" (broken glass) Cafe au lait spots with the Cost of Maine appearance. Fibrous dysplasia is an uncommon bone disorder in which scar-like (fibrous) tissue develops in place of normal bone. This irregular tissue can weaken the affected bone and cause it to deform or fracture.

Osteopetrosis

In extremities; Ivory white in coot (every bone) Marble bone appearance (Really white everything.

Teeth marks in the jts./ disc spaces

Infection

Type 2 Spondylolisthesis*T

Isthmic (Break through Pars) aka "Spondilolytic Spondilolisthesis"

Galeazzi Fx

Just know the areas fx

Pancreatic Calcification

L1, L2, L3 area it crosses over the L2,L3 vertebral bodies. (Spotty Whites) *What else is seen?-Calcified Pancreas

Aneurysmal Bone Cyst (ABC)

Less than 20 yo Diaphyseal/ Metaphyseal location -Eccentrically located (Off to the side *T) -Not from Cortex to Cortex *Blood Fluid Tumor Associated w/ "Blisters of Bone appearance" & finger in "Balloon Appearance" *Send to orthopedist, most likely to cause pathological fx b/c of of thinning of cortex.

Chondroblastoma

Less than 20 yo Epiphyseal/Metaphysal location

Unicameral Bone Cyst (Metadiphyseal)

Less than 20 yo Diaphyseal/metaphyseal location Centrally located on side of cortex, all the way to the other) Associated with: -Fallen Fragment Sign Fluid filled tumor -Cortex to Cortex -No Bone expansion

Calcified Prostate

Location: Sits on top of the pubic symphysis Color: White Spotty Males higher than 50 yr. old, urinary problems. Labs: PSA, Acid Phosphotase Metastasis (M/c lumbar spine): Alkaline Phosphatase.

Fracture's Vertebras

Loss of anterior body height by 25% or more. Always check "POSTERIOR BODY HEIGHT" (NO DECREASE, so its no pathological like MM, Lytic)

Darker Color indicates

Lytic Met's or MM *Bone gets dark in color; Both could cause a pathological collapse; Loss of ANTERIOR/POSTERIOR body height. (Both)

Osteochondroma

M/c BBT of appendicular skeleton. Two types: 1.Pedunculated -Aka "Coat Hanger Enostosis", "Cartilagenous Cap", "Califlower Lession" 2.Sessile -Aka " Broad Based Exostosis (Do NOT confuse with Ewing Sarcoma; periosteal reaction) They grow away nearest the closest joint. HME: Hereditary Multiple Exostosis -Multiple osteochondromas HME's can be "Quasimalignant" -Malignant degeneration and transformation Do Not confuse with lytics. -It ends it.

Osteoma

M/c BBT to affect the: -SKULL M/c found in the: -Frontal sinus Best seen on the: -Caldwell projection Gas is black; sinuses are field with gas. Sinuses- black.

Enchondroma

M/c benign bone tumor of the: "Hand" (Not to worry about other places.) May have a stippled appearance . (Tiny white densities within the enchondroma) Refer to orthopedist

Lunate

M/c dislocated carpal bone. Dislocation: Associated with "Pie Sign" (You can have a Fx also of the Scaphoid.) AVN: Keinbocks dz (whiter)

Hogkin's X-rays

M/c form of metastais in ages less than 30, typically MALES. Ivory White vertebra w/ Anterior Body Scalloping. Unilateral Hilar Lymphadenopathy in Caucasian (males) seen on the PA chest view. Needs Biopsy to confirm (Reed Stenberg cells)

Renal Artery

M/c found at L2 (sits in front) Calcification: -Dark center outlined in white. -Smaller than L2 vertebral body. Aneurysm: -Goes in front of and around L2. AAA does NOT goes in them.

Scaphoid

M/c fractured carpal bone. (90% will fx through the middle) Dislocation: Associated with "Signet Ring Sign" and increase jt. space between scaphoid and lunate called "Terry Thomas Sign/Davis Letterman Sign" AVN: Preisser's DZ (Scaphoid will appear whiter in color; can occur with fx also.)

Synoviochondrometaplasia

M/c joint affected JOINT affected is the knee. Color and shape: White popcorn Location: In and Around the Synovial Joints. It COULD be outside the bone.

AAA

M/c location for an Aortic Aneurism: -Sits in front of L2, L3,L4. AAA on A-P view appears like Half moon shape coming from the side. Radiographic Signs: -Aortic Dilation -Curvilinear Calcification -Fusiform(spindle shape) Appearance Special Test: -Droppler US -Diagnostic US -Ultrasonography -CT (Best) Refer to a : Cardiovascular Specialist. Worst Scenario- Hypovolemic schock due to rupture. Could be seen in a Lateral View as well.

Osteosarcoma

M/c malignancy found in children. Less than 30 yr. Increased Alkaline Phosphotase Special Test: Bone Scan (Hot) Refer to Oncologist.

Paget's

Males higher than 50 years old. -Starts on cortex of bone. Not just one part, check the "overall" color of the medulla will be whiter. Stages: 1.Lytic/Destructive 2.Combined 3.Sclerotic 4.Malignant/Osteosarcoma *Causes cortical thickening in spine called -Picture Frame Vertebrae -Increased Bone Density -Coarsened trabeculae -Bone enlargement -Bone softening causing basilar invagination Bowing deformities: -Saber Shin Tibia/Sheppard's Crook Saber shin. Right tibia(normal) Saber shin is a malformation of the tibia. It presents as a sharp anterior bowing, or convexity, of the tibia. A shepherd crook deformity refers to a coxa varus angulation of the proximal femur, classically seen in femoral involvement by fibrous dysplasia, although may be seen in other disorders such as Paget disease of bone and osteogenesis imperfecta. Radiographic Findings in extremities: -Osteoporosis Circumstricta -Blade of Grass -Candle Flame -Sheaves of Wheat/Grain -Cortical thickening on pelvic inlet **Brim Sign* Labs: Increases Alkaline phosphatase/Urinary Hydroxyproline Special Test: Bone Scan (Hot)

Teeth marks in the bone

Malignancy

3 things looking for:

Mallum Coxa Seniis DJD of the HIP AVN of the HIP

Atelectasis

Mediastinal shift to the same side On collapse lung will display increased density.

Gout

Metabolic Arthritide -More than 40 yo due to overproduction of URIC ACID -More than 40, in MALES, because females loose their Uric acid from menstruation. -Foods high in purines : Red meats, Red wine, Aged cheeses, Beer & Pork. Extremely painful, red, hot swollen joints. 70& Usually mono-articular with the m/c site at the MTP of the big toe -PODAGRA**** GOUT goes to the coldest areas of the body. If more than one joint:***No distribution pattern (only arthrotide) Tophi crystals may be seen **OVER-HANGING MARGIN; JUSTARTICULAR EROSIONS. Labs: Increased Uric Acid, +ESR, Leukocytosis Special test: Joint aspiration for uric crystals. Pharmacology: Acute: Cholchicine Chronic-Allopurinol 70% affects one joint. (PODAGRA), starts from the outside, works its way in the bone. Affects the bone **ABOVE/BELOW** THEN YOU GET THE CRYSTALS IN JOINT SPACE. Case management: -Dietary Changes -Pure Cherry juice (urase)) -Tart Cherry extracts

Loss of anterior body height by 10-15%

Mild compression fx (Does NOT cause multiple endplates irregularities.) Scheurman's (causes multiple endplates irregularities.

Fibrous Dysplasia

Monostotic form (70%) associated with the: -Rind Sign (Thick sclerotic border) Physiologic resorption of normal bone replaced by fibrous tissue. Causes deformity (Saber Shin Tibia and Sheppard's Crook) "Ground Glass" Appearance Cafe Au lait spots with the "Coast of Maine" Appearance. Shapped like an egg in the Ilium (part 4); but FYI m/c in FEMUR.

Systemic Lupus Erythematosus

More on Clinical Tests See Dx of OPQRST Females, sunlight precipitates a skin rash (malar/butterfly rash) Oral ulcers Discoid Lesions Alopecia (Hair loss from the scalp or elsewhere on the body.) Raynaurds Phenomenom Can cause ULNAR DEVIATION of the phalanges w/ NO joint destruction. -"Rebound effect" Labs: +LE prep +FANA/+ANA +ESR Leukoplecia Thrombocytopenia +Coombs Comanage with Rheumatologist

Mallum Coxa Seniis

More than 40 Severe DJD of the Hip (Bad hip old) -Lost of Superior Lateral Joint Space -Lipping/Spurring -Subchondral Cyst (Also known as "Geo", appears like a Benign bone tumor, bit its NOT**) -2 benign bone tumors that affect the Epiphysis: GCT (20-40); Chondrobastoma (less than (20)

Chondrosarcoma/Fibrosarcoma

More than 40 yr.

Blastic Metastasis

More than 40 yrs; ivory white vertebra; no cortical thickening or bone enlargement, NO DEFORMITY. Labs: Increased Alkaline Phosphatase Special Test: Bone Scan (HOT) Prostate carcinoma could lead to "Blastic Metastasis" -Urinary problems, back pain.

Hemangioma X ray

Most common benign bone tumor of the : -Spine Will appear with "vertical striations" called: Jail Bar Corduroy Claw Appearance

Lateral Thoracic View

Motive is Routine Always take a look at the Case Hx. Trauma does NOT cause Osteoporosis even if the pt. has it. Start w/ front of Vertebral bodies

Flexion/Extension Views

Motive of view: -Abnormal motion/fusion checking ligamentous stability. -Read them the same way as a Lat. Cervical. **Contraindicated in: 1.Cervical Fractures with the exception of Clay Shovler's. 2.Traumatic Dislocations (RA) 3. Malignancies 4. Infections

Cervical Obliques Anatomy

Motive: IVF's -Read from the TOP Down. Posterior Oblique (PO) marker will be in front of the spine. Anterior Oblique (AO) will be behind the spine. Use these rules: AO- same side IVF PO-opposite side IVF Examples: RAO: Right IVF LAO: Left IVF RPO:Left IVF LPO:Right IVF 1st IVF seen on the film is the C2-C3 IVF. The first number is the disc, second number is the nerve existing. Boundaries of IVF: -Anterior: Bodies, Uncinates -Superior/Inferior: Pedicles -Posterior: Facets **Check the size and shape of each IVF .

Lateral Sacrum

Motive: Pain/ Dysfunction 3 common conditions: 1.Fracture- Jagged line 2.Benign Bone Tumor- A circle inside anywhere. (M/c in there is the Giant Cell Tumor) 3.Malignancy (Lytic Mets)

Extremity Views

Motive: Pain/Dysfunction Read from PROXIMAL to DISTAL Anatomically; Atypical view=Trauma -Something you will not normally see. Check the periosteum: -For a periosteal reaction 1.Spiculated Aka "Radiating/Sunburst" 2.Parallel Aka "Laminated"

Lumbar Obliques

Motive: Pars; check facets (*Facet Arthrosis, Facet imbrication: over-riding of the facets) *Read from the top-down. Markers: Posterior Oblique (PO) marker goes in front of the spine. Anterior Oblique (AO) marker goes behind the spine. LOA: Lumbars Opposite Pars Anterior Oblique Examples: LAO: Right Pars RAO: Left Pars LPO: Left Pars RPO: Right Pars 1. Check the Pars Fx 2.Check the Facets for DJD and Facet imbrication Facet Imbrication is overriding of the facets. Two lines:Macnab's/Haslay's "S" Curve *If the ear of the scottie dog crosses the highest portion of the inferior endplate above.

Anterior Posterior Lower Cervical View (APLC view)

Motive: Rotine Do NOT confuse C4 tracheal airshadow w/ Spina Bifida; its normal. (MACH SHADOW)

A-P Lumbopelvic View

Motive: Routine

Lateral Lumbar Film

Motive: Routine Film

Ollier's Dz

Multiple Enchondromas 10-50% rate of malignant degeneration. refer to orthopedist

Osteopoikilosis

Multiple bone islands (Tiny white Pokodots) Tiny white densities within the enchondroma **Symmetrical in color/shape** Labs: No labs; to rule out blastic mets (Alkaline Phosphatase) DDX: Blastic MEts (not symmetrical ) X rays views: A-P pelvis Bilateral Hands and Feet

Brodies Abscess

Night Pain relieved by Aspirin AKa"Chronic Osteomyelitis)"

Osteoid Osteoma

Night pain relieved by "Aspirin" Radiolucent "central nidus" w/ severe reactive sclerosis" and Bone expansion. Similar to "Brodie's Abscess"

3 things to look for:

Osteopetrosis Osteopoikilosis Synoviochondrometaplasia

If more than two vertebral bodies with jail bar appearance/ Corduroy appearance:

Osteoporosis

Osteoporosis Circumscripta

Osteoporosis circumscripta cranii (also known as osteolysis circumscripta) refers to discrete radiolucent regions of the skull on plain radiographs. They are often seen in context of the lytic (incipient-active) phase of Paget disease of the skull, but may be observed in other circumstances as well, e.g. hyperparathyroidism, leontiasis ossea. Osteoporosis circumscripta is well-defined lysis, most commonly in frontal bone producing well-defined geographic lytic lesion in skull. Represents early destructive phase of disease active stage. "Cotton wool" appearance represents mixed lytic and blastic pattern of thickened calvarium (later stage)

Osteosarcoma hand

Osteosarcoma (also called osteogenic sarcoma) is the most common type of cancer that starts in the bones. The cancer cells in these tumors look like early forms of bone cells that normally help make new bone tissue, but the bone tissue in an osteosarcoma is not as strong as that of normal bones.

Grey Bone/ Grey Soft Tissue

Ostopenia (X-finding; not a condition) "MM", "HPT", "Osteporosis", "AS", "Paget's" can all cause Osteopenia. -DEXA Scan. If there is NO other condition on the film--> OSTEOPOROSIS (Pencil thin cortices.)

3. DJD

Over the age of approx. 40 Bilateral whitening on ilia and sacral sides of the SI Jts.

Lytic Mets of Pedicle

Owl Winking Sign (Lytic Mets Eats one pedicle) Blind vertebra sign (2 pedicles missing from Lytic Mets)

The Lung

P-A Chest 98% of Dx. Lateral Chest: can see sternum. -Fx sternum, pathological collapse of vertebral body, hiatal hernia

Wrist Views

P-A is for any: -CARPAL BONE Lateral Wrist: -RADIUS, ULNA, LUNATE. Scaphoid/Lunate in the radius. Ulnar Deviation: -Scaphoid/Lunate Colle's Fx Smith's Fx Fx Triquetrum Scaphoid Fx Lunate Dislocation

Sacrum Shape

Paget's Fx's Congenital Anomalies Fibrous Dysplasia (P.F.C.F.)

Paget's Pelvic Brim

Paget's Cortical Thickening of pelvic inlet. "Brim Sign", Unilateral/Bilateral It does NOT have to be bilateral only.

Alterations of shape (PFC)

Pagets Fracture Congenital Anomalies

Type 5 Spondylolisthesis

Pathological (obvious pathology on that segment) (Not coming)

Infection

Pt. presents with a fever, chills, possible HX of trauma/recent surgery and a warm, tender, swollen joint. Refer out; Chest X-rays; Sputum Culture ; WBC count. Alters disc space in size/color, eats away the surrounding endplates.

Klippel Feil Syndrome

Pt.Multiple congenital blocks Associated with Sprengle's Deformity (unilateral nondescoid of the scapula) and Omovertebral Bone (Calcification of Rhomboids)

Congenital Hip Dysplasia

Putti's Triad: -Hypoplastic femoral head -Shallow acetabular shelf -Femoral head outside of acetabulum Ortho's: Telescoping, Ortolani's, Barlow's, Allis, Shapels. DDx with Hip Dislocation -Trauma, Fx's -Putti's triad In a normal hip, the ball at the upper end of the thighbone (femur) fits firmly into the socket, which is part of the large pelvis bone. In babies and children with developmental dysplasia (dislocation) of the hip (DDH), the hip joint has not formed normally.

Rheumatoid Arthritis X rays

RA in feet: -Lick Candystick appearance. Still Dz in children. 2 m/c locations : -Carpals, will fuse them -MCP's always involved -Symmetrical Distribution -Bilateral uniform joint loss of joint space -Localized juxtarticular/periarticular osteoporosis (near the joint) -Rat bite erosions -DIP's spared -Haygarth's (MCP) -Bouchards (PIP) -Swann Neck Deformity -Boutonniere Deformity -Phalanges to ulnar/fibular deviation. (Lanois Deformity) Labs: +RA Latex (Rheumatoid Factor) +FANA +ESR +CRP Normocytic Normochromic Anemia (Also for MM) Has to be in the MCP's, symmetrical distribution, majority of the bones involved. Destruction is similar from joint to joint. RA never affects the DIPS! ANA FANA -Scleroderma (Chronic hardening and tightening of the skin and connective tissues.) -Systemic LUPUS Erythromatocyte Case management: -Flexion/Extension X-ray before we adjust. -Check ADI FYI: Juxtaarticular: Near a joint. For example, a juxta-articular fracture is a break near a joint. Rat (a.k.a. mouse) bite erosions are seen in gout and refer to punched out erosions with sclerotic and overhanging margins. lanois deformity of Rheumatoid arthritis - fibular deviation of the digits and dorsal subluxation at the metatarsal phalangeal joints.

Osteochondritis Dessicans of the Talus

Radiolucent Half-moon shape through tallus, Crescent sign. Medial aspect

Raynards Phenomenom

Raynaud's (ray-NOHZ) disease causes some areas of your body — such as your fingers and toes — to feel numb and cold in response to cold temperatures or stress.

Renal Artery (Calcification/Aneurysm)

Right next to L2 (Renal Artery Calcification), smaller than L2, Dark center, outline to white. Renal Aneurysm- goes over the top and all around to the side of L2. Also seen in Lateral view.

APOM View

Routine film but best to see the DENS & ATLAS. 7 steps

Mach line

Rule out of all of them. (It's a shadow.)

Trauma

See fx on film or Bony callus on the film.

Preisser AVN

See pic in document

Fracture of Tallar dome

See picture

Spondylolisthesis

Slippage of the vertebral body with or w/o a fracture. 5 Types: Type 1-Dysplastic (Congenital) Type 2*- Isthmic Type 3-Degenerative (DJD of facets) Type 4- Traumatic Flexion/Extension/ Oblique X-rays/ MRI (*Isthmic Type 2) Special test: SPECT Test Case management: If stable, could adjust; Supine & William Flexion exercises.

Sacrum Spina Bifida

Spina Bifida -vertical radiolucency in the middle of the sacrum. -Pain on extension, William's Flexion exercises.

Step 1

Start above clavicles and compare side to side. Vascular markings on both sides of bronchus normal Lung apices should be dark. If one side white and one side dark : White side is the problem. -White density in one side. 2 possibilities: 1.Pneumonia (consolidation; fluid in the base of the lung) -Increase white density well below the clavicle w/ a *straight line across** Tactile Fremitus: Positive in Bronchophony/Egophony -sounds travels better through fluid. Ex: Pool Percussion: -Dull Refer: Send to ER Case Hx: -Increase WBC count -Productive cough (rusty brown sputum, app. 10 days) -recent visit to the hospital 2. Pancoast tumor -Apical Lung tumor; does NOT go well below the clavicle. -If does, there is no straight line across. Horner's Syndrome (interruption of the cervical sympathetics): -PAM Pancoast is horny Refer to oncologist.

A-P Ankle

Start with the fibula first. *M/c fx site

TP's

TP fx vs. Non-Union of TP TP Fx -Bone displaced from itself Fulcrum's Fx's: QL's/ iliopsoas (m. that attach to the TP) Ex: 18 yr. old football player hit from behind that has flan pain. -Kidney contusion -Hematuria Non-union of TP -It's in place, smooth cortical margins

Oblique Hand

Taken for Bone Bennet's Fx (1st metacarpal) Boxer's Fx (2/3 metacarpal) Bar Room Fx (4/5 metacarpal) If Bar room is NOT in answer sheet, pick Boxer's fx. Osteosarcoma chondrosarcoma.

Talengectasi

Telangiectasia is a condition in which widened venules (tiny blood vessels) cause threadlike red lines or patterns on the skin. These patterns, or telangiectases, form gradually and often in clusters. They're sometimes known as "spider veins" because of their fine and weblike appearance.

Risser's Scoliosis Sign

The Risser sign is an indirect measure of skeletal maturity, whereby the degree of ossification of the iliac apophysis by x-ray evaluation is used to judge overall skeletal development. Mineralization of the iliac apophyses begins at the anterolateral crest and progresses medially towards the spine.

Blade of Grass (Paget's)

The blade of grass sign, also called the candle flame sign, refers to the lucent leading edge in a long bone seen during the lytic phase of Paget disease of bone. The blade of grass sign is characteristic of Paget disease of bone. This is akin to osteoporosis circumscripta cranii seen in the skull.

Brown's Tumor

The brown tumor is a bone lesion that arises in settings of excess osteoclast activity, such as hyperparathyroidism. It is not a true neoplasm, as the term "tumor" suggests; however, it may mimic a true neoplasm

Crescent sign

The crescent sign of avascular necrosis is seen on conventional radiographs and refers to a linear area of subchondral lucency seen most frequently in the anterolateral aspect of the proximal femoral head

Type 4 Salter Harris Fx

Through Epiphysis, Growth Center and Metaphysis Through

Type 3 Salter Harris Fx

Through Growth center and Epiphysis Lower

Osgood Schlatter's

Tibial Apophysitis (Avulsion of he tibial fracture) 10-16+/-, kids. Pinpoint pain and swelling, commonly involved in jumping sports/Soccer Hip Flexion, Knee Extension Attachment of the Quadriceps muscles Case management: -Stop athletic activities, Cho-Pat Brace, heal in 3-5 weeks, Stretch Quads, Contract Hamstrings. Best Dx: Lat. Knee X-rays (for boards purposes) Apophysitis" is the medical term used to indicate inflammation and stress injury where a muscle and its tendon attaches to the area on a bone where growth occurs in a child or adolescent, an area called the "growth plate." Apophysitis is commonly seen in active, growing children and adolescents.

Osteopoikilosis

Tiny white Pokodots symmetrical in size/shape. Multiple bone islands (enostomas) -Asymptomatic Could NOT have it outside the bone. No labs for this condition. M/c found in the: -Humerus -A-P Pelvis* -Hands/Feet* Labs to rule out other condition: -Alkaline Phosphatase b/c we want to rule out blastic mets.

Lateral Ankle/Foot X rays

Trace out each bone for Fx's. Check for Calcaneal Spurs -Heel spur: m/c cause is plantar fascitis, 2nd cause is Reiter's Check for AVN's -Severe's Dz -Whitening of the back of the calcaneus, also fragmentation. Bone displaced from itself Fx of Navicular Bone Fx of Calcaneus

APOM (Step 4)

Trace out the Dens making sure it is in place. Leaning or Tilting dens suggests Dens Fx.

*Loss of the anterior body height by 25% or more:

Trauma Ostopenia Infection Malignancy

AVN of the Hip

Trauma, corticosteroids (2 causes) -Superior Lateral Space is preserved -Femoral Head will appear whiter in color. 8 months to 2 years.

Type 4 Spondylolisthesis

Traumatic (break through pedicles) -Hangman's Fx

3 types of Fx's of Dens

Type 1: Through tip Type 2: Through the base.**Test Type 3: Down into the C2 body. (Not to worry)

Salter Harris Fx's

Types 1-5 A Salter-Harris fracture or growth plate fracture is a fracture that involves the epiphyseal plate or growth plate of a bone. It is thus a form of child bone fracture. It is a common injury found in children, occurring in 15% of childhood long bone fractures.

Limbus bone vs. Avulsion Fx

Utilize the anterior vertebral vertebral body line.

Step 2

Vascular markings should be seen in both sides. If missing in both sides: -COPD Emphysema (Bilateral) -Trouble getting air out. -Creates a barrel chest -Air (gas) is dark. *Bilateral darken lung fields *Narrowed Compressed Heart -Aka "Stove Pipe Heart" *Horizontal ribs *Flattening of Diaphragmatic Domes -fluid will accommodate in the costophrenic recesses. Percussion: Hyper-resonant b/c of air trapped there. Tactile Fremitus: Decreased b/c its not fluid in there is air. Increase pitch on expiration wheeze.

Calcified Spleen

Very lateral on films. Left lateral T12, L1. (Large white calcification) Picture anatomy NOT Calcified Spleen

Infection

WBC count, No Fx, No Bony callus.

Uncinate Arthrosis

When the Uncinates Lateral Bend Away

C2 is ?

Whiter than C3 (Normal b/c its bigger bone; Also Bifid Spinouses are normal)

Sacrum Color

Whiter: Blastic Mets/Pagets Darker: Lytic Mets/M.M., Benign Bone Tumors

Gallstones X-rays

also known "Cholelisthiasis" Location: L1, L2 (Iliac Crest go all the way up to L1,:2) Color: Dark Center, Outlined in white. Affiliated with 9F's -Female,Fat, Flatulent, Fourty years old, Fertile, Fatty Meals. Pain referral to the inferior border of the right scapula. (Viscerosomatic) Murphy's Inspiratory Arrest Special Test: -Ultrasound -Cholecystogram** Case management: Refer to Internist, Recommend Dietary Changes.

Posterior Ponticle

calcification of the Atlantoccipital ligament. (Arcuate foramen- vertebral artery, suboccipital nerve and C1 nerve.)

Neutral Lateral Cervical (Step 11)

check for the back of the BODIES, PEDICLES and Facets. A.Posterior Bodies: Height and Destructions. Lytic Mets: Teeth Marks B.Pedicles: Check for slipping bodies (Subluxation vs. dislocation) Subluxation: slippage of vertebral body, anterior or posterior, by 10-15% with facets still lining up. *Named from the bottom up. Name segment on top. Posterior-retrolisthesis Anterior-Anterolesthesis *Only used for subluxations. Dislocation: slippage of the vertebral body, anterior or posterior, by 25% or more with **FACET PURGING (tirandose en algo) AND SPINOUS FANNING** (Open space of spinouses) Named from the TOP DOWN. Named the top segment on top also. If Facets are involved and do NOT LINNED UP- DISLOCATION. C.Facets (3 things can happen): Dislocations, Destruction or Fusions. Dislocation: Trauma or ligament instability. Destruction: Facet Arthrosis (DJD of facets) Fusion: Congenital-Fusion of facets w/ same spinolaminar junction line. Acquired: Fusion of facets w/ separate distinct spinolaminar line. (RA/AS) -2 conditions: 1.RA (No marginal syndesmophytes) 2.AS (Marginal Syndesmophytes, thin egg shell calcifications.

Lytic Mets of thumb

eating away metacarpal Do NOT make you differentiate vs. GOUT, NO infection, infection goes over the joint space)

Osteopetrosis

every bone involved Hereditary; absence of bone marrow. Anemia; Hepatosplenomegaly "Bone within bone" (early) "Sandwich vertebra" (late) FYI: Hepatosplenomegaly is a disorder where both the liver and spleen swell beyond their normal size, usually due to an infection such mononucleosis or viral hepatitis. It may also be a sign of another more serious illness such as a lysosomal storage disorder. FYI: Osteopetrosis, literally "stone bone", also known as marble bone disease, Albers-Schönberg disease is an extremely rare inherited disorder whereby the bones harden, becoming denser, in contrast to more prevalent conditions like osteoporosis, in which the bones become less dense and more brittle, or osteomalacia,

Malignancy

loss of ANTERIOR/POSTERIOR body height. Pathological collapse: MM, Metastic Lytic

Scoliosis

named for the largest or major curve. named on the side of convexity. Rotatory: SP's deviate away from convexity. Simple: Spinouses deviate towards the side of convexity. M/c- Adolescent Idiopathic Simple Scoliosis Test- Adam's Orthopedic Test X-rays Lines: Ferguson's & Cobbs Case management: 25 years or younger Measures up to 20 degrees: Adjust and monitor (Risser's and Wrist films), X-rays every 3 months, Lat medial starts then fuses medial to lateral-Risser's. Measures 21-40: Refer to orthopedist for bracing (Milwakee Brace) Measures over 40 degrees: Surgical consultation. If left untreated could let to: Early DJD, Cardiopulmonary compromise.

Ulnar Deviation Film

w/ fx this one

Stippled appearance

with numerous small dots or specks.