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
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| OM for Lumbar Obliques | to see pars and facets
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| OM for PA ulnar deviation of wrist | ONLY to see scaphoid and lunate
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| OM for Cervical flex/ext | check for abnormal motion and/or fusion, stability or instability of ligs
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| Adi space for children/adults | no more than 3mm adults, 5mm child
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| 20-30% of downs pts have | absence of transverse lig
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| 5 things that can cause increased adi | Trauma, ta, as, psoriatic a, reiters
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| Without measuring, normal width of adi is | a thin black line
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| 4 possible reasons atlas goes ant | inc. adi, fx dens, unstable OO, agenesis of dens
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| 3 possible reasons atlas goes post | fx dens, unstable OO, agenesis of dens
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| Hyperostosis, 2 akas | candle wax drippings, ant. Spinal bridging
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| 2 akas for DISH | forrestier’s dx, ankylosing hyperostosis
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| DISH mc seen in what pop | males over 50
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| DISH preserves | disc space height and never involves facets
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| DISH has a correlation with what other disease | DM 30%
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| Management of DISH | adjust them! Send to endocrinologist if have DM
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| Marginal syndesmophytes | AS
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| Non-marginal syndesmophytes | psoriatic or reiters if not DISH
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| Conjunctivitis/uveitis, urethritis, arthritis | reiters
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| Silver scales on extensors, pitted nails | psoriatic arthritis
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| Hyperostosis with facet fusion | psoriatic or reiters (only time to consider these based on findings in the spine)
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| Avulsion fx of ant-inf aspect of vert body | teardrop fx
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| Teardrop fx mc occurs | c2
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| MOI for teardrop fx | hyperextension
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| Unstable fx that can cause acute anterior cervical cord syndrome | teardrop
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| Think MOPIT | Loss of anterior body height of 25% or more
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| MOPIT | malignancy, osteoporosis, pagets, infection, trauma
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| Radiolucent line at base of dens | dens fx, OO, agenesis of dens, mach line
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| If majority of dens is above occiput | PFT, pagets, fibrous dysplasia, trauma
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| Chamberlains line | from back of hard palate to post aspect of foramen magnum – dens should be no more than 7mm above
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| 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
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| If dens is displaced, 2 possible reasons | fx, unstable OO
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| Os Odontoideum akas (2) | non-union of dens, un-united dens
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| Management for dens fx | stabilize neck and send to hospital asap
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| Alteration of shape of vertebral bodies | PFC- pagets, fx, congenital anomalies
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| Bone turns whiter | blastic mets, pagets
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| Bone turns darker | lytic mets, mm
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| Blastic mets age | >40
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| Pagets age | >50
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| Ivory white vertebra in someone under 30 | then and ONLY then think hodgkins lymphoma
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| MC cause of ivory white vertebra | blastic mets
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| Blastic mets on bone scan | hot/responsive
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| Picture frame vertebra | pagets
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| Cortical thickening | pagets
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| Subchondral sclerosis aka | eburnation
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| Subchondral sclerosis seen in | djd
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| Vacuum phenomenon | djd
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| Destruction on both sides of joint | infection – the only thing that will do this
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| If post. Arch of atlas is absent thing 3 things | cut away in surgery, eaten by malignancy, congenitally absent
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| #1 ddx for fracture is | non union
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| Military spine c/s | alordotic
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| Reverse curve c/s | kyphotic
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| Decrease in posterior body height | MOPIT
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| Only dx malignancy with decrease in post body height if | there is no sign of infection or trauma
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| Loss of ant. Body height with post height usually preserved | osteoporosis
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| Wedge shaped vertebra | osteoporosis
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| V shaped defects in vertebra | trauma
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| If you see decreased body height on an AP film you can take it to the bank | there is decreased post body height
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| <10% slippage of one vertebra on another with facets stil in line | subluxation
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| Line drawn on the posterior vert. bodies- should be smooth, unbroken curve | george’s line
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| 25% slippage or more of one vert on another with facets overriding or perching | dislocation
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| Management of vertebral dislocation | immediate surgical referral
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| Fanning of spinouses | facet dislocation
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| 4 ligs must be torn for fanning of spinouses to occur | supraspinous, interspinous, ligamentum flavum, capsular lig
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| If facets are dislocated ddx | ra, trauma
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| If facets are destroyed ddx | ra, oa
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| If facets are fused ddx | ra, as
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| Djd of facets | facet arthrosis
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| Missing spinal laminar line | spina bifida occulta
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| Spina bifida of c1 | spondyloschisis
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| If SPs are absent 3 possible reasons why | surgery, malignancy, congenitally absent
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| Spinous fx in c/s | clay shoveler’s fx
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| Mc location for clay shovelers | c6, c7, t1
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| Moi for clay shovelers | hyperFLEXION
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| Calcification of posterior atlanto-occipital lig | posterior ponticle
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| AKAs for posterior ponticle | pons posticus, ponticus posticus
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| Hole formed by calcification of posterior atlanto-occipital lig | arcuate foramen
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| Arcuate foramen transmits | suboccipital nerve, vertebral artery
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| Posterior ponticle vs clay shoveler’s fx, most clinically significant | PP
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| Post. Ponticle associated with | VBAI
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| Retropharyngeal space measurements | at c4 no more than 7mm
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| Retrotracheal space measurements | at c6 no more than 20mm
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| Causes of c/s soft tissue swelling | trauma, infection, malignancy
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| Wasp-waist deformity | congenital block
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| horizontal radiolucencies going through vertebra | usually mach lines
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| vertical radiolucency through vertebra | fx
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| hemispherical spondylosclerosis associated with/indicates | assoc w/discogenic spondylosis, ind-uncinate arthrosis
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| best view to dx occipitalization is | c/s flexion
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| c/s film, jaw angles up | extension
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| c/s film jaw angled down | flexion
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| multiple congenitally blocked vertebra in c/s | klippefeil syndrome
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| low hair line, short webbed neck, dec. c/s rom | klippefeil syndrome
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| 20-30% of pts w/klippefeil will have | sprengles deformity
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| Unilateral non-descent of the scapula | sprengles deformity
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| Calcification of rhomboid musculature | omovertebral bone
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| Omovertebral bone associated with | klippefeil syndrome
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| In order to dx sprengles deformity you must have | bil. Shoulder shot
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| Fusion due to surgery | arthrodesis
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| Fusion due to pathology | ankylosis
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| Pattern of AS | starts in SI T/L jctn then fuses up and down the spine (so always affects lower c/s before upper
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| OM of APOM | to view dens and arches of atlas
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| Smiling arch of atlas | posterior arch
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| Frowning arch of atlas | anterior arch
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| Mach lines seen in APOM | smiling arch, frowning arch, occiput, gap between incisors makes vert. radiolucency through dens
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| Thin radiolucent line through base of dens | fx
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| Thick radiolucent line through base of dens | OO
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| Dens fracture above the base of the dens | type 1 dens fx
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| Dens fracture through the base of the dens | type 2 dens fx
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| Dens fracture below the base of the dens | type 3 dens fx
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| MC dens fracture | type 2
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| Most unstable/severe dens fracture | type 3
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| Unequal or enlarged peridontoid interspaces- possible | Jefferson burst fx
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| Overhang of lateral mass of c1 on c2 on one side with equal shift on opposite side | normal atlas laterality
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| Overhang of lateral mass of c1 on one side but does not shift equal amount on opposite side | Jefferson burst fx
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| Bilateral overhang of lateral masses on c2 | Jefferson burst fx
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| MOI for Jefferson burst fx | vertical blow to top of head
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| Biggest thing affecting TPs of atlas | congenital anomalies
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| Congenital anomalies of TPs of atlas | epi-transverse process, paracondylar/paramastoid process
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| Mc finding in ST in and around jaw | lymph node calcification
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| Big, thick diamond-shaped radiolucency above the base of the dens | Os Terminale
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| DDX Os terminale with | Type 1 Dens fx
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| AKAs for Os terminale | non-union dens, ununited dens
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| Last set of TPs that point upward | T1
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| C7 TP extending PAST TP of T1 | hypertrophic elongated TP of C7
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| AKA for TOS | neurovascular compression syndrome
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| TP fx MC | L/S
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| Mc thing affecting uncinates | uncinate arthrosis aka uncinate hypertrophy
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| Normal appearance of uncinates | vertical, like the ears on batman’s helmet
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| Flattening or laterality of uncinates | blunting of uncinates, indicative of uncinate arthrosis
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| MC cause of IFV encroachment | uncinate arthrosis
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| Never see spina bifida at what level | c4
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| Spinous Fx MOI | hyperflexion
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| Double spinous sign | clay shoveler’s fx
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| If see tracheal deviation on APLC | follow up with chest film. Can only dx deviation on APLC, but why is it deviated?
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| V shaped opacity in ST in APLC | Carotid artery calcification
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| Mc area for carotid arteries to calcify | bifurcation
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| Single white density in ST on APLC film | could be Carotid artery calcification or lymph node calcification
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| Multiple round white densities in a vertical line on APLC | carotid artery calcification
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| Multiple round white densities scattered (not in a vert. line) on APLC | lymph node calcification
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| 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
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| First IVF seen | C2/C3
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| Normal anatomy of IVFs | and border: bodies and uncinates, sup/inf border: pedicles, post border: facets
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| Hourglass IVF | IVF encroachment
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| 3 things that can make IVF larger | lytic mets of pedicle (very rare), agenesis of pedicle, neurofibroma
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| Expansile tumor of nerve root | neurofibroma
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| Dumbbell shaped IVF | neurofibroma
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| Tx for neurofibroma | surgery
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| Multiple neurofibromas | neurofibromatosis
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| Neurofibromatosis aka | Von Reklinghausens dx
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| Café au lait spots with smooth borders | Neurofibromatosis
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| Café au lait spots | on abdomen, coast of maine (jagged) or California (smooth)
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| Café au lait spots with jagged borders | fibrous dysplasia
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| Hyperostosis of 4 or more segments | DISH
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| Decreased body height of post body of several segments in a row | MM
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| Loss of anterior body height in TS by 15% but no endplate irregularities | mild compression fx
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| Loss of at least 15% ant body heigt with jt destruction that is grossly unequal from jt to jt | infection
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| Slight loss of ant body height in TS with relatively similar destruction of jts, endplate irregularities of 3 or more vertebra | scheurmann’s dx
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| Severe scheurmanns dx causes | increased thoracic kyphosis (hump back)
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| Scheurmann’s Dx AOO | 10-16yo
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| Avascular necrosis of secondary growth centers- specifically endplates in TS | Scheurmann’s DX
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| Major cause of all AVNs | trauma
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| Untreated AVN leads to | early DJD
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| Best modality for seeing AVN | MRI- best results, bone scan- more cost effective
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| Management of scheurmann’s | refer to ortho surgeon for bracing.
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| Impression on anterior half of vertebra – borders jagged and irregular | schmorle’s node
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| Impression on posterior half of vertebra and on the inferior aspect. Smooth border. | nuclear impression
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| Cupids bow deformity on AP film | nuclear impression
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| 3+ schmorles nodes in same region | Scheurmann’s Dx
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| DDX Hyperparathyroidism with | osteopetrosis
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| Rugger jersey spine | Hyperparathyrodism
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| Marble bone | osteopetrosis
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| Metabolic dx commonly assoc. with brown’s tumor | HPT
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| Bone within bone | Osteopetrosis
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| Albers Schanbergs Dx | Osteopetrosis
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| Sandwich vertebra | osteopetrosis
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| Sclerosis along sup and inf aspect of vert from ant to post | HPT
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| Sclerosis along sup and inf asp of vert, post- curves off on ant aspect | osteopetrosis
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| Ivory white vertebra larger than those surrounding | pagets
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| Radiolucency through LS pedicle | fx
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| Displacement of LS pedicle | fx
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| Pars fx with no anterior slippage | spondylolysis
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| Test performed on anyone with hardcore neurological symptoms | myelogram
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| ST in LS L2-L4 | Abdominal Aorta
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| Normal width of aorta is what fraction of LS vert | ½ - ¾
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| Half moon shape in LS ST | Aneurysm
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| Curvilinear calcification in LS ST | aneurysm
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| Best imaging modality for suspected AAA | CT with Contrast is best, Transverse diagnostic US most cost effective
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| Aneurysm present if AA is greater than | 3.8cm
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| Immediate surgical referral if AA greater than | 5cm
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| Emergency AAA if you see (3 things) | hypovolemic shock, tearing pn over abdomen, sudden onset of severe LBP that is deep and boring
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| Limbus bone | nothing more than a congenital non-union
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| Bony fragment on anterior aspect of vert body with no displacement | limbus bone
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| Bony fragment on ant aspect of vert body with displacement | avulsion fx
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| For AS, every segment affected must be affected | bilaterally and symmetrically
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| Spondylo that is usually a congenital anomaly causing ant. Slippage | (I) dysplastic
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| Spondylo, usually a pars fx causing ant slippage | (II) isthmic
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| Spondylo – djd of facets causing ant. Facet | (III) degenerative
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| Spondylo usually caused by a pedicle fx | (IV) traumatic
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| Spondylo caused by lytic mets, mm, pagets | (V) pathological
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| Inverted napoleon hat sign | spondylo (at least grade 3) on AP film
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| AKAs for inverted napoleon hat sign | bowline of brailsford, gendarme cap sign, man of arms sign
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| Meyerding grading system | I:1-25%, II: 26-50%, III: 51-75%, IV: 76-100%, V: >100%
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| If L5 has slipped >100% and dropped down it is referred to as | spondyloptosis
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| Spurring at anterior superior aspect of the sacrum | buttressing phenomenon
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| Buttressing phenomenon is an excellent sign of | stable spondylo
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| + Mcnabbs line | facet imbrications
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| Bilateral symmetrical fusion of SI jts | AS
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| Bilateral symmetrical whitening of the iliac side of SI jt. DDX | DJD vs OCI
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| Bilateral symmetrical whitening of iliac side of SI jt and inferior portion of sacral side of SI jt. | djd
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| Bilateral symmetrical whitening of iliac side of SI jt and sacral side of SI jt not affected. | OCI
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| Management of OCI | adjust SI jts, pelvic/trochanteric stabilizer belt, nutrition
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| Triangular sclerosis of SI | OCI
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| SI condition usually seen in multiparous women between 20 and 40 | OCI
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| Alteration of shape of ilium | PFF – pagets, fracture, fibrous dysplasia
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| Alteration of color of ilium | whiter: blastic mets or pagets, darker: lytic mets, mm, benign bone tumors
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| Line drawn across top of iliac crest should bisect | L4/L5 disc
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| Last set of ribs that point down | T12
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| If L5 is flattened or wider than normal then referred to as | spatulated TP
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| Alteration in shape of sacrum | PFCF- pagets, fracture, congenital anomaly, fibrous dysplasia
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| Mc benign tumor of the sacrum | giant cell tumor
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| Vertical radiolucency in sacrum | spina bifida
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| U shaped radiolucency in sacrum | spina bifida
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| Asymmetrical L5/S1 facets | facet tropism
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| Can’t have bilateral facet tropism, if both facets are sagittal then you have | bilateral sagittal facets
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| Vertical striations in a single vertebra | hemangioma
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| If body height is similar to the height of the pedicles you know you have | a crushed vertebra
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| Ddx for crushed vertebra | malignancy, infection, trauma – malignancy only if no other signs of infection or trauma
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| Winking owl sign | missing pedicle
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| Winking owl sign, pedicle that is present is sclerotic when compared to others surrounding | agenesis of pedicle
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| Winking owl sign, pedicle that is present looks the same when compared to others surrounding | lytic mets
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| Crushed vertebra with no signs of trauma or infection, no involvement of pedicles | MM
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| MM only affects areas with | active bone marrow (skull, sternum, ribs, spine, pelvis, prox femur, prox humerus)
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| MM on bone scan | cold
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| Reverse A/G ratio | mm
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| Labs for MM | IgG-M spike, reverse A/G ratio, Bence Jones Proteinuria, normocytic normochromic anemia, rouleaux formation
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| Rouleaux formation | stack of coins appearance- on blood smear RBCs stacked up against each other
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| In order to Dx TP fx without displacement, you must see | a bony callous (appears as a cloud of white density surrounding bone.
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| Cheerio sign ddx | renal artery calcification and renal artery aneurysm
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| 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)
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| If you see Abdominal Aorta on AP film | AAA – you should never see Abd. Aorta on AP film
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| Only see gallstones on xray when they calcify which is about % | 10% of the time- black center outlined in white.
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| Gallstones seen | at L1-L2 area straight above the top of the iliac crest and only on the right
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| Kidney stones can be seen on xray % | 90% of the time
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| Kidney stones found | L1-L3 area unilateral or bilateral close to spine
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| Ddx kidney stones and renal artery calcification | by location renal artery calcification much closer to the spine.
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| Calcification of renal calyces | staghorn calculus (can see outline of renal calyces)
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| Ddx from renal contrast study by | looking for contrast in ureters
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| ST in pelvic inlet with big and small round white densities | blastic mets
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| Appears to be DJD of symphysis pubis | Osteitis Condensans Pubi
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| OCP in males as a result of | prostate surgery
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| OCP in females as a result of | child birth
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| First sign of AS | romanus lesion
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| Romanus lesion | erosion of corner of vertebra (not seen on xray, picked up on MRI)
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| Shiny corner sign | first XRAY sign of AS
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| Bamboo spine | AS, marginal syndesmophytes
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| Trolley Track Sign | AS, calcification of the capsular ligs
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| Dagger sign | AS, connects all SPs together by calcifying the supraspinous and interspinous ligs
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| Star sign | AS, white density at sup aspect of SI jts – only seen when SI jts are fused
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| Ghost Joint | term used to describe SI jt when theyre fused
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| Failure of ossification of center of vertebra | butterfly vert. sagittal cleft/midline defect
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| Failure of segmentation of vertebra | congenital block
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| What appears to be a disck in a congenital block (4 names) | remnant/rudimentary/hypoplastic/vestigial disc
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| Spina bifida of S1 in combination with elongated SP of L5 | knife clasp deformity
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| Knife clasp deformity can not cause meningeal irritation bc | there are no meninges this far down only sacral nerves
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| 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
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| Best DDX in pelvis is | age
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| Thin black line in area of growth center pt age | <20
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| Thin white line in area of growth center pt age | 20-30
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| No lines in area of growth center, no signs of DJD pt age | 30-40
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| Signs of djd pt age | >40
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| Dx affecting pelvis/hip of young pts | Slipped capital femoral epiphysis, Legg Calve Perthes Dx
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| Dx affecting pelvis/hip of older pts | blastic mets, pagets, lytic mets, MM, DJD, osteoporosis, RA, AVN of hip
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| Dx affecting pelvis/hip of both young and older pts | Fibrous dysplasia, Congenital hip dysplasia
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| 3 conditions affect lower SI jts | AS, DJD, OCI
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| Putti’s triad indicates | congenital hip dysplasia
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| Putti’s triad consists of | smaller than normal femur head, shallow acetabulum, femur head outside of acetabulum
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| Ortho test for congenital hip dysplasia | ortalani’s aka flexion abduction test
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| Management of congenital hip dysplasia | refer to orthopedic surgeon, application of A-brace aka flexion-abduction brace
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| Normal femur head, normal acetabulum, femur head outside of acetabulum | hip dislocation
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| 90° angle below symphysis pubis | male
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| 140-150° angle below symphysis pubis | female
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| Indentations on ilii called paraglenoid sulci | female
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| Upside down martini glass | male
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| Upside down margarita glass | female
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| Sup-lat jt space preserved in hip, sclerosis only femur head side | AVN of hip
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| Sup-lat jt space decreased, sclerosis on femur and acetabular side | DJD
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| Malum coxae synilis | severe djd of the hip
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| 5 things to look for in ST of Pelvic Inlet | uterine fibroids, calcified prostate, ureter stones, phleboliths, bladder stones
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| Mulberry mass in center of pelvic inlet | uterine fibroid
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| Round stippled white density sitting on symphysis pubis | calcified prostate
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| Small round white density found above a line drawn across the top of the femur heads | ureter stones
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| Small round white density found below a line drawn across the top of the femur heads | phleboliths
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| Large stippled, multi faceted white densities found below a line drawn across the top of the femur heads, more centrally located | bladder stones
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| Anytime bone appears whiter than surrounding bones (other than prox femur and carpal bones) assume | blastic mets until proven otherwise
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| Bilateral ischial AND Bilateral pubis fractures | straddle fracture
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| Line drawn along the inner portion of the pelvic inlet and the outer obturator | kohlers line
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|
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| + kohlers line if | femur head crosses protrucio acetabuli
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|
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| Bilateral protrusion acetabuli | Otto’s pelvis
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|
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