Anything and everything you need to know about NBCE Part IV Xray in Study Stack

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OM for Cervical Oblique film

to see IVFs ONLY

OM for Lumbar Obliques

to see pars and facets

OM for PA ulnar deviation of wrist

ONLY to see scaphoid and lunate

OM for Cervical flex/ext

check for abnormal motion and/or fusion, stability or instability of ligs

Adi space for children/adults

no more than 3mm adults, 5mm child

20-30% of downs pts have

absence of transverse lig

5 things that can cause increased adi

Trauma, ta, as, psoriatic a, reiters

Without measuring, normal width of adi is

a thin black line

4 possible reasons atlas goes ant

inc. adi, fx dens, unstable OO, agenesis of dens

3 possible reasons atlas goes post

fx dens, unstable OO, agenesis of dens

Hyperostosis, 2 akas

candle wax drippings, ant. Spinal bridging

2 akas for DISH

forrestier’s dx, ankylosing hyperostosis

DISH mc seen in what pop

males over 50

DISH preserves

disc space height and never involves facets

DISH has a correlation with what other disease

DM 30%

Management of DISH

adjust them! Send to endocrinologist if have DM

Marginal syndesmophytes

Non-marginal syndesmophytes

psoriatic or reiters if not DISH

Conjunctivitis/uveitis, urethritis, arthritis

reiters

Silver scales on extensors, pitted nails

psoriatic arthritis

Hyperostosis with facet fusion

psoriatic or reiters (only time to consider these based on findings in the spine)

Avulsion fx of ant-inf aspect of vert body

teardrop fx

Teardrop fx mc occurs

MOI for teardrop fx

hyperextension

Unstable fx that can cause acute anterior cervical cord syndrome

teardrop

Think MOPIT

Loss of anterior body height of 25% or more

MOPIT

malignancy, osteoporosis, pagets, infection, trauma

Radiolucent line at base of dens

dens fx, OO, agenesis of dens, mach line

If majority of dens is above occiput

PFT, pagets, fibrous dysplasia, trauma

Chamberlains line

from back of hard palate to post aspect of foramen magnum – dens should be no more than 7mm above

McGregor’s Line

from back of hard palate to base of occiput – dens should be no more than 8mm above in males, 10 in females

If dens is displaced, 2 possible reasons

fx, unstable OO

Os Odontoideum akas (2)

non-union of dens, un-united dens

Management for dens fx

stabilize neck and send to hospital asap

Alteration of shape of vertebral bodies

PFC- pagets, fx, congenital anomalies

Bone turns whiter

blastic mets, pagets

Bone turns darker

lytic mets, mm

Blastic mets age

>40

Pagets age

>50

Ivory white vertebra in someone under 30

then and ONLY then think hodgkins lymphoma

MC cause of ivory white vertebra

blastic mets

Blastic mets on bone scan

hot/responsive

Picture frame vertebra

pagets

Cortical thickening

pagets

Subchondral sclerosis aka

eburnation

Subchondral sclerosis seen in

djd

Vacuum phenomenon

djd

Destruction on both sides of joint

infection – the only thing that will do this

If post. Arch of atlas is absent thing 3 things

cut away in surgery, eaten by malignancy, congenitally absent

#1 ddx for fracture is

non union

Military spine c/s

alordotic

Reverse curve c/s

kyphotic

Decrease in posterior body height

MOPIT

Only dx malignancy with decrease in post body height if

there is no sign of infection or trauma

Loss of ant. Body height with post height usually preserved

osteoporosis

Wedge shaped vertebra

osteoporosis

V shaped defects in vertebra

trauma

If you see decreased body height on an AP film you can take it to the bank

there is decreased post body height

<10% slippage of one vertebra on another with facets stil in line

subluxation

Line drawn on the posterior vert. bodies- should be smooth, unbroken curve

george’s line

25% slippage or more of one vert on another with facets overriding or perching

dislocation

Management of vertebral dislocation

immediate surgical referral

Fanning of spinouses

facet dislocation

4 ligs must be torn for fanning of spinouses to occur

supraspinous, interspinous, ligamentum flavum, capsular lig

If facets are dislocated ddx

ra, trauma

If facets are destroyed ddx

ra, oa

If facets are fused ddx

ra, as

Djd of facets

facet arthrosis

Missing spinal laminar line

spina bifida occulta

Spina bifida of c1

spondyloschisis

If SPs are absent 3 possible reasons why

surgery, malignancy, congenitally absent

Spinous fx in c/s

clay shoveler’s fx

Mc location for clay shovelers

c6, c7, t1

Moi for clay shovelers

hyperFLEXION

Calcification of posterior atlanto-occipital lig

posterior ponticle

AKAs for posterior ponticle

pons posticus, ponticus posticus

Hole formed by calcification of posterior atlanto-occipital lig

arcuate foramen

Arcuate foramen transmits

suboccipital nerve, vertebral artery

Posterior ponticle vs clay shoveler’s fx, most clinically significant

Post. Ponticle associated with

VBAI

Retropharyngeal space measurements

at c4 no more than 7mm

Retrotracheal space measurements

at c6 no more than 20mm

Causes of c/s soft tissue swelling

trauma, infection, malignancy

Wasp-waist deformity

congenital block

horizontal radiolucencies going through vertebra

usually mach lines

vertical radiolucency through vertebra

hemispherical spondylosclerosis associated with/indicates

assoc w/discogenic spondylosis, ind-uncinate arthrosis

best view to dx occipitalization is

c/s flexion

c/s film, jaw angles up

extension

c/s film jaw angled down

flexion

multiple congenitally blocked vertebra in c/s

klippefeil syndrome

low hair line, short webbed neck, dec. c/s rom

klippefeil syndrome

20-30% of pts w/klippefeil will have

sprengles deformity

Unilateral non-descent of the scapula

sprengles deformity

Calcification of rhomboid musculature

omovertebral bone

Omovertebral bone associated with

klippefeil syndrome

In order to dx sprengles deformity you must have

bil. Shoulder shot

Fusion due to surgery

arthrodesis

Fusion due to pathology

ankylosis

Pattern of AS

starts in SI  T/L jctn  then fuses up and down the spine (so always affects lower c/s before upper

OM of APOM

to view dens and arches of atlas

Smiling arch of atlas

posterior arch

Frowning arch of atlas

anterior arch

Mach lines seen in APOM

smiling arch, frowning arch, occiput, gap between incisors makes vert. radiolucency through dens

Thin radiolucent line through base of dens

Thick radiolucent line through base of dens

Dens fracture above the base of the dens

type 1 dens fx

Dens fracture through the base of the dens

type 2 dens fx

Dens fracture below the base of the dens

type 3 dens fx

MC dens fracture

type 2

Most unstable/severe dens fracture

type 3

Unequal or enlarged peridontoid interspaces- possible

Jefferson burst fx

Overhang of lateral mass of c1 on c2 on one side with equal shift on opposite side

normal atlas laterality

Overhang of lateral mass of c1 on one side but does not shift equal amount on opposite side

Jefferson burst fx

Bilateral overhang of lateral masses on c2

Jefferson burst fx

MOI for Jefferson burst fx

vertical blow to top of head

Biggest thing affecting TPs of atlas

congenital anomalies

Congenital anomalies of TPs of atlas

epi-transverse process, paracondylar/paramastoid process

Mc finding in ST in and around jaw

lymph node calcification

Big, thick diamond-shaped radiolucency above the base of the dens

Os Terminale

DDX Os terminale with

Type 1 Dens fx

AKAs for Os terminale

non-union dens, ununited dens

Last set of TPs that point upward

C7 TP extending PAST TP of T1

hypertrophic elongated TP of C7

AKA for TOS

neurovascular compression syndrome

TP fx MC

L/S

Mc thing affecting uncinates

uncinate arthrosis aka uncinate hypertrophy

Normal appearance of uncinates

vertical, like the ears on batman’s helmet

Flattening or laterality of uncinates

blunting of uncinates, indicative of uncinate arthrosis

MC cause of IFV encroachment

uncinate arthrosis

Never see spina bifida at what level

Spinous Fx MOI

hyperflexion

Double spinous sign

clay shoveler’s fx

If see tracheal deviation on APLC

follow up with chest film. Can only dx deviation on APLC, but why is it deviated?

V shaped opacity in ST in APLC

Carotid artery calcification

Mc area for carotid arteries to calcify

bifurcation

Single white density in ST on APLC film

could be Carotid artery calcification or lymph node calcification

Multiple round white densities in a vertical line on APLC

carotid artery calcification

Multiple round white densities scattered (not in a vert. line) on APLC

lymph node calcification

Follow up for lymph node calcification

history of or current infection? Send out for US or for biopsy of lymph nodes to check for lymphomas

First IVF seen

C2/C3

Normal anatomy of IVFs

and border: bodies and uncinates, sup/inf border: pedicles, post border: facets

Hourglass IVF

IVF encroachment

3 things that can make IVF larger

lytic mets of pedicle (very rare), agenesis of pedicle, neurofibroma

Expansile tumor of nerve root

neurofibroma

Dumbbell shaped IVF

neurofibroma

Tx for neurofibroma

surgery

Multiple neurofibromas

neurofibromatosis

Neurofibromatosis aka

Von Reklinghausens dx

Café au lait spots with smooth borders

Neurofibromatosis

Café au lait spots

on abdomen, coast of maine (jagged) or California (smooth)

Café au lait spots with jagged borders

fibrous dysplasia

Hyperostosis of 4 or more segments

DISH

Decreased body height of post body of several segments in a row

Loss of anterior body height in TS by 15% but no endplate irregularities

mild compression fx

Loss of at least 15% ant body heigt with jt destruction that is grossly unequal from jt to jt

infection

Slight loss of ant body height in TS with relatively similar destruction of jts, endplate irregularities of 3 or more vertebra

scheurmann’s dx

Severe scheurmanns dx causes

increased thoracic kyphosis (hump back)

Scheurmann’s Dx AOO

10-16yo

Avascular necrosis of secondary growth centers- specifically endplates in TS

Scheurmann’s DX

Major cause of all AVNs

trauma

Untreated AVN leads to

early DJD

Best modality for seeing AVN

MRI- best results, bone scan- more cost effective

Management of scheurmann’s

refer to ortho surgeon for bracing.

Impression on anterior half of vertebra – borders jagged and irregular

schmorle’s node

Impression on posterior half of vertebra and on the inferior aspect. Smooth border.

nuclear impression

Cupids bow deformity on AP film

nuclear impression

3+ schmorles nodes in same region

Scheurmann’s Dx

DDX Hyperparathyroidism with

osteopetrosis

Rugger jersey spine

Hyperparathyrodism

Marble bone

osteopetrosis

Metabolic dx commonly assoc. with brown’s tumor

HPT

Bone within bone

Osteopetrosis

Albers Schanbergs Dx

Osteopetrosis

Sandwich vertebra

osteopetrosis

Sclerosis along sup and inf aspect of vert from ant to post

HPT

Sclerosis along sup and inf asp of vert, post- curves off on ant aspect

osteopetrosis

Ivory white vertebra larger than those surrounding

pagets

Radiolucency through LS pedicle

Displacement of LS pedicle

Pars fx with no anterior slippage

spondylolysis

Test performed on anyone with hardcore neurological symptoms

myelogram

ST in LS L2-L4

Abdominal Aorta

Normal width of aorta is what fraction of LS vert

½ - ¾

Half moon shape in LS ST

Aneurysm

Curvilinear calcification in LS ST

aneurysm

Best imaging modality for suspected AAA

CT with Contrast is best, Transverse diagnostic US most cost effective

Aneurysm present if AA is greater than

3.8cm

Immediate surgical referral if AA greater than

5cm

Emergency AAA if you see (3 things)

hypovolemic shock, tearing pn over abdomen, sudden onset of severe LBP that is deep and boring

Limbus bone

nothing more than a congenital non-union

Bony fragment on anterior aspect of vert body with no displacement

limbus bone

Bony fragment on ant aspect of vert body with displacement

avulsion fx

For AS, every segment affected must be affected

bilaterally and symmetrically

Spondylo that is usually a congenital anomaly causing ant. Slippage

(I) dysplastic

Spondylo, usually a pars fx causing ant slippage

(II) isthmic

Spondylo – djd of facets causing ant. Facet

(III) degenerative

Spondylo usually caused by a pedicle fx

(IV) traumatic

Spondylo caused by lytic mets, mm, pagets

(V) pathological

Inverted napoleon hat sign

spondylo (at least grade 3) on AP film

AKAs for inverted napoleon hat sign

bowline of brailsford, gendarme cap sign, man of arms sign

Meyerding grading system

I:1-25%, II: 26-50%, III: 51-75%, IV: 76-100%, V: >100%

If L5 has slipped >100% and dropped down it is referred to as

spondyloptosis

Spurring at anterior superior aspect of the sacrum

buttressing phenomenon

Buttressing phenomenon is an excellent sign of

stable spondylo

+ Mcnabbs line

facet imbrications

Bilateral symmetrical fusion of SI jts

Bilateral symmetrical whitening of the iliac side of SI jt. DDX

DJD vs OCI

Bilateral symmetrical whitening of iliac side of SI jt and inferior portion of sacral side of SI jt.

djd

Bilateral symmetrical whitening of iliac side of SI jt and sacral side of SI jt not affected.

OCI

Management of OCI

adjust SI jts, pelvic/trochanteric stabilizer belt, nutrition

Triangular sclerosis of SI

OCI

SI condition usually seen in multiparous women between 20 and 40

OCI

Alteration of shape of ilium

PFF – pagets, fracture, fibrous dysplasia

Alteration of color of ilium

whiter: blastic mets or pagets, darker: lytic mets, mm, benign bone tumors

Line drawn across top of iliac crest should bisect

L4/L5 disc

Last set of ribs that point down

T12

If L5 is flattened or wider than normal then referred to as

spatulated TP

Alteration in shape of sacrum

PFCF- pagets, fracture, congenital anomaly, fibrous dysplasia

Mc benign tumor of the sacrum

giant cell tumor

Vertical radiolucency in sacrum

spina bifida

U shaped radiolucency in sacrum

spina bifida

Asymmetrical L5/S1 facets

facet tropism

Can’t have bilateral facet tropism, if both facets are sagittal then you have

bilateral sagittal facets

Vertical striations in a single vertebra

hemangioma

If body height is similar to the height of the pedicles you know you have

a crushed vertebra

Ddx for crushed vertebra

malignancy, infection, trauma – malignancy only if no other signs of infection or trauma

Winking owl sign

missing pedicle

Winking owl sign, pedicle that is present is sclerotic when compared to others surrounding

agenesis of pedicle

Winking owl sign, pedicle that is present looks the same when compared to others surrounding

lytic mets

Crushed vertebra with no signs of trauma or infection, no involvement of pedicles

MM only affects areas with

active bone marrow (skull, sternum, ribs, spine, pelvis, prox femur, prox humerus)

MM on bone scan

cold

Reverse A/G ratio

Labs for MM

IgG-M spike, reverse A/G ratio, Bence Jones Proteinuria, normocytic normochromic anemia, rouleaux formation

Rouleaux formation

stack of coins appearance- on blood smear RBCs stacked up against each other

In order to Dx TP fx without displacement, you must see

a bony callous (appears as a cloud of white density surrounding bone.

Cheerio sign ddx

renal artery calcification and renal artery aneurysm

Ddx renal artery calcification and renal artery aneurysm by

size. If “cheerio” is smaller than L2: renal artery calcification, if larger than L2: renal artery aneurysm. (if spans 3+ vertebra: AAA)

If you see Abdominal Aorta on AP film

AAA – you should never see Abd. Aorta on AP film

Only see gallstones on xray when they calcify which is about %

10% of the time- black center outlined in white.

Gallstones seen

at L1-L2 area straight above the top of the iliac crest and only on the right

Kidney stones can be seen on xray %

90% of the time

Kidney stones found

L1-L3 area unilateral or bilateral close to spine

Ddx kidney stones and renal artery calcification

by location renal artery calcification much closer to the spine.

Calcification of renal calyces

staghorn calculus (can see outline of renal calyces)

Ddx from renal contrast study by

looking for contrast in ureters

ST in pelvic inlet with big and small round white densities

blastic mets

Appears to be DJD of symphysis pubis

Osteitis Condensans Pubi

OCP in males as a result of

prostate surgery

OCP in females as a result of

child birth

First sign of AS

romanus lesion

Romanus lesion

erosion of corner of vertebra (not seen on xray, picked up on MRI)

Shiny corner sign

first XRAY sign of AS

Bamboo spine

AS, marginal syndesmophytes

Trolley Track Sign

AS, calcification of the capsular ligs

Dagger sign

AS, connects all SPs together by calcifying the supraspinous and interspinous ligs

Star sign

AS, white density at sup aspect of SI jts – only seen when SI jts are fused

Ghost Joint

term used to describe SI jt when theyre fused

Failure of ossification of center of vertebra

butterfly vert. sagittal cleft/midline defect

Failure of segmentation of vertebra

congenital block

What appears to be a disck in a congenital block (4 names)

remnant/rudimentary/hypoplastic/vestigial disc

Spina bifida of S1 in combination with elongated SP of L5

knife clasp deformity

Knife clasp deformity can not cause meningeal irritation bc

there are no meninges this far down only sacral nerves

Most to least clinically significant congenital anomalies affecting L5/S1

1: knife clasp deformity, 2: lumbosacral transitional seg, 3: facet tropism, 4: spina bifida of L5 or S1, 5: hypertrophic enlarged TP of L5

Best DDX in pelvis is

age

Thin black line in area of growth center pt age

<20

Thin white line in area of growth center pt age

20-30

No lines in area of growth center, no signs of DJD pt age

30-40

Signs of djd pt age

>40

Dx affecting pelvis/hip of young pts

Slipped capital femoral epiphysis, Legg Calve Perthes Dx

Dx affecting pelvis/hip of older pts

blastic mets, pagets, lytic mets, MM, DJD, osteoporosis, RA, AVN of hip

Dx affecting pelvis/hip of both young and older pts

Fibrous dysplasia, Congenital hip dysplasia

3 conditions affect lower SI jts

AS, DJD, OCI

Putti’s triad indicates

congenital hip dysplasia

Putti’s triad consists of

smaller than normal femur head, shallow acetabulum, femur head outside of acetabulum

Ortho test for congenital hip dysplasia

ortalani’s aka flexion abduction test

Management of congenital hip dysplasia

refer to orthopedic surgeon, application of A-brace aka flexion-abduction brace

Normal femur head, normal acetabulum, femur head outside of acetabulum

hip dislocation

90° angle below symphysis pubis

male

140-150° angle below symphysis pubis

female

Indentations on ilii called paraglenoid sulci

female

Upside down martini glass

male

Upside down margarita glass

female

Sup-lat jt space preserved in hip, sclerosis only femur head side

AVN of hip

Sup-lat jt space decreased, sclerosis on femur and acetabular side

DJD

Malum coxae synilis

severe djd of the hip

5 things to look for in ST of Pelvic Inlet

uterine fibroids, calcified prostate, ureter stones, phleboliths, bladder stones

Mulberry mass in center of pelvic inlet

uterine fibroid

Round stippled white density sitting on symphysis pubis

calcified prostate

Small round white density found above a line drawn across the top of the femur heads

ureter stones

Small round white density found below a line drawn across the top of the femur heads

phleboliths

Large stippled, multi faceted white densities found below a line drawn across the top of the femur heads, more centrally located

bladder stones

Anytime bone appears whiter than surrounding bones (other than prox femur and carpal bones) assume

blastic mets until proven otherwise

Bilateral ischial AND Bilateral pubis fractures

straddle fracture

Line drawn along the inner portion of the pelvic inlet and the outer obturator

kohlers line

+ kohlers line if

femur head crosses protrucio acetabuli

Bilateral protrusion acetabuli

Otto’s pelvis

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Created by: ringjrkl on 2012-05-16