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Diagnostic Imaging 3

Glenohumeral joint 4-5mm
Acromiohumeral joint 7-11mm
Acromioclavicular joint 3-4mm
Coraclavicular joint 11-13mm
AP elbow hand supinated
Medial Oblique Elbow Hand pronated
Lateral Elbow Flexed 90 with thumb pointed up.
Jones Projection Tangential Olecranon
Jones Projection Joint space between trochlea and olecranon process. Ulnar groove.
Capitellum view Lateral position. Tube is cephalad 45.
AP elbow coronoid fossa is superimposed upon the olecranon.
Olecranon foramen or Supratrochlear Humeral foramen. Allows for more extension.
Radioulnar synostosis Bone fusion. Bilateral and familial, extending 3-6 cm. Limit or prevent supination and pronation of forearm.
Later projection Radial tuberosity is present just distal to the radial neck.Pseudocyst
Anterior fat pad Small triangular radiolucency. Anterior to humerus on lateral view.
Posterior fat pad adjacent to the posterior aspect of distal humerus. NEVER NORMAL. Seen with displacement of anterior fat pad.
Supinator fat stripe Lateral elbow view. Parallel to the ventral spect of the proximal third of radius. Lies withing 1cm of ventral margins of the radius. Normal chevron appearance to trabecular pattern in distal humerus.
Supracondylar process Exostosis of bone(spur) projecting from anteromedial aspect of distal humerus. toward the elbow joint.
Supracondylar process Struther's Ligament. from the process to the medial epicondyle.
Capitellum 1-8 months
Radial Head 3-6 years
Internal(medial)epicondyle 3-7 years
Trochlea 9-10 yrs
Olecranon 6-10 yrs
External(lateral) epicondyle 9-13 yrs
Critoe Earlier in girls.
Trochlea is NEVER seen before the medial epicondyle
Fusing of elbow occurs 14-15yrs. Except for medial epicondyle which closes at 18 -19 years.
Anterior Humeral Line Drawn tangential to anterior aspect of humerus on lateral view, past the elbow joint.
Anterior Humeral Line Normal: The line should fall through the middle one third of the capitellum.
Anterior Humeral line Abnormal: May suggest a supracondylar fracture
Radiocapitellar Line Lateral projection: This line is drawn down the Center of and parallel to the long axis of the radius extending through joint space.
Radiocapitellar line should pass center of the capitellum on all standard views. Could be dislocation of the Radial head or fracture of the capitellum.
Standard wrist series PA wrist, PA Medial Oblique Wrist, Lateral Wrist.
PA medial Oblique wrist Joint space between trapezium and trapezoid.
Lateral wrist Determining relationship of the carpal bones with the distal radius following trauma.
Accessory view of wrist PA Wrist with Ulnar Deviation and Carpal Tunnel view
PA wrist with Ulnar deviation AKA Ulnar flexion. Helps rule out scaphoid fracture.
Scaphoid fat stripe Extends from the trapezium to the radial styloid process.
Scaphoid fat stripe Between radial collarteral ligament and the tendons of the EXTENSOR POLLICIS BREVIS and ABDUCTOR POLLICIS LONGUS.
90% of fractures of the radial compartment the fat stripe is displaced lateral or obliterated.
The radius articulates with the head of the ulna at the ulnar notch.
All carpal joint interspaces should NOT exceed 2mm.
The distal radioulnar articulation should NOT exceed 2mm.
Capitate birth to 6mos
Hamate birth to 6mos
Triquetrum .5-3.5 yrs
Lunate 1.5-4.5 yrs
Navicular 3-9 yrs
Trapezium 3-9 yrs
Trapezoid 3-9 yrs
Pisiform 7-13 yrs
Distal Radial Epiphysis .5-2 yrs
Distal Ulnar epiphysis 5.5-9.5 yrs.
Three arcs of carpal alignment Along proximal of proximal. ALong distal of proximal. Along proximal or distal.
Pie sign(rotational abnormality) A triangular shape of the lunate with overlap of the capitate.
Pie sign PA view
Ulnar is 1-2mm shorter than radius
Ulnar + More load on the ulna. predisposed to lunate/triquestral ligament damage
Ulnar - Greater stress upon lunate. Predisposed it AVN(avascular necrosis)
avascular necrosis Keinbock's Disease
M/C site in the wrist is accessory ossicle at the distal aspect of ulnar sytloid process.
Os Hamuli Proprium Ununited hook of Hamate
Carpal Coalition aka Congenital synostosis
M/C site of carpal coalition Lunate and triquetrum
Madelung's Deformity Retarded growth of medial portion of distal radial epiphysis. Ulnar slant.
Bayonette wrist deformity resulting from posterior subluxation of the ulna.
Patient make OK sign to help position palm at 45 tilts towards film for medial oblique wrist projection.
Trapezium-Trapezoid joint space is better viewed Patient make OK sign.
Pronator Quadratus Fat Stripe Made by pronator quad fascial plane on lateral projection.
Distal radial articular surface slopes 10-15 degrees volarly(to palm)
Carpal Angle On PA wrist. First line is drawn tangent to the proximal surface of the scaphoid and lunate. Second line drawn tangent to proximal surfaces of the lunate and triquetrum
Carpal angle NORMAL 128-142 degrees
Standard Hand views PA hand, Medial Oblique Hand, Lateral Hand
Medial Oblique Hand palm of hand 45 degrees to film
Norgaard's Projection (Ball Catcher's view) Used to detect early radiographic changes in RHEUMATOID ARTHRITIS.
Accessory views Norgaard's Projection, Finger series, Thumb series.
Finger series PA, Oblique and Lateral
Thumb series AP, Oblique and Lateral
Diaphyseal is secondary site to tendinous attachment
Distal phalanx of the 4th digits is longer and thicker than the 2nd.
Distal Tufts(aka ungual tufts) Should be uniform. Lysis of the distal tufts is associated with SCLERODERMA as well as with other arthritic and endocrine disorders.
First metacarpal articulates with Trapezium
Second metacarpal articulates with Trapezoid
3rd metacarpal articulates with capitate
4th metacarpal articulates with hamate on the radial side.
5th metacarpal articulates with hamate on the ulnar side.
Syndactyly during 5th fetal week. Results in webbing or fusion. Demonstrated by soft tissue fusion between the fingers and any osseous anomalies of development.
Syndactyly m/c in males. and M/c developmental anomaly of the hand.
Brachymetcarpy shortening of metacarpal
Clindactyly radial or ulnar deviation of the distal phalanx. Radial deviation of the 5th DIP.
Clindactyly of the 5th finger is trisomy 21 (Down Syndrome)
Kirner deformity(dystelephalangy) claw like deformity. Autosomal dominant
Symphalangism absence of the interphalangeal joints with resultant fusion of the phalanges.
Vascular of nutrient canals. nutrient canals of the hand. Nice smooth margins.
2 sesamoids base of proximal phalanx of thumb.
1 sesamoid interphalangeal joint in 72%
1 sesamoid base of 5th mcp 82%
Sesamoids of thumb 12-14 yrs
Medial sesamoid lies within adductor pollicics
Lateral sesamoid lies with flexor pollicis brevis.
Metacarpal sign PA projection of the hand. Single line drawn tangential to the 4th and 5th mtc head.
Normal MTC 3 mtc falls below(proximal)this line.
Abnormal MTC Short 4th metacarpal. Juvenile chronic arthritis, sickle cell anemia, trauma, Turner syndrome
Steinberg thumb sign Tip should protrude thru clenched fist. Marfan's, homocystinuria, or normal variant.
Compact bone is thickest in the diaphysis. Tapers toward metaphysis
Trabecule are formed along lines of stress Wolff's law
Short bones do not have physis
Medullary space of flat bones diploe(diploic space)
Irregular bones cranial base and vertebrae.
Epiphysis composed of cartilage. Signifies the end of the growth period.
Subchondral bone Articular cortex and the bone immediately beneath it.
Apophysis pathologically should be thought of as epiphysis. Site for attachment of ligaments or tendons.IE trochanters tuberosities and tubercles.
Enthesis actual site of attachment of tendons and ligaments.
Physis radiolucent area between the epiphysis and metaphysis. aka epiphyseal plate, growth plate, or growth center. Provides longitudinal growth.
Zone of Provisional calcification junction of metaphysis and physis. Precursor to bone formation.
Metaphysis between zone of provisional calcification and diaphysis.
Metaphysis most metabolically active and m/c site for osseous tumors and infection.
Diaphysis aka shaft lies between both metaphyses. longest part of bone. Provides strength and bone marrow
Periosteum Membrane on diaphysis and metaphysis.
Epiphyseal periosteum DOES NOT EXIST.
Inner cambium or periosteum is metabolically labile.
Endosteum covers all trabeculae and inner cortical margins. Helps maintain cortical thickness or the diaphysis.
ABCS Alignment, Bones, Cartilage, and Soft tissue
Clinical data age, sex, race, history.
Polyostotic multiple lesions.
Monostotic (More common) Single lesion.
Monostotic usually indicate tumor or infection.
Symmetrical and equally distributed lesions caused by disseminated disease(leukemia)
Asymmetric and haphazardly arragned lesions metastasis
Chordoma selectively involves clivus and sacral/coccxygeal junction
Chondroblastoma occur in the epiphysis
Medullary lesions within bone. thinning cortex, endosteal scalloping. Fibrous and cartilaginous lesions.
Cortical denoted by eccentric position of the lesion. Destruction, distortion, or expansion of cortical bone.
Cortical lesions invoke a periosteal response.
Periosteal not normally seen on normal radiograph
Extra-osseous lesion soft tissue tumor. May cause pressure erosion of the adjacent bone.
Most slow-growing tumors are <6mm at time of discovery.
Aggressive lesions are larger exceptions:aneurysmal bone cyst, simple bone cyst, Giant Cell tumor, and Fibrous dysplasia
Short lesions (<6cm) secondary lesions. Metastatic disease.
Long lesions Primary disorders.
Imperceptible margination ill-defined, wide zone, AGRESSIVE
Sharp non-agressive
Cortical thinning thins towards metaphysis from diaphysis.
Tumors cause localized cortical thinning.
Osteoporosis thins all cortices.
Endosteal scalloping frequently seen in cartilaginous or fibrous tumors(NON-AGRESSIVE)
Multiple myeloma aggressive
Corical thickening may occur locally or generally.
Bulging of intact cortex non-agressive
Permeative or moth-eaten agressive
Neoplastic bone destruction caused by pressure of hyperemia-generated resorption.
Geographic circular or oval. SOAP BUBBLE. NON-AGGRESSIVE
Permeative lesions are more aggressive than moth-eaten.
Moth-eaten 2-5mm
Permeative numberous tiny 1mm
Osteoblastic lesions increased density.
mixed lesions lytic and blastic patterns. Seen in Mixed metastatic disease.
matrix is important for categorizing.
Intraosseous Fat lucency with a central calcification. very rare
Soft tissues lipomas often found
Stippled calcification small, discrete, spotty. Enchondromas of hand M/C
Flocculent calcification "popcorn" larger and spotty.
Arc and ring calcification in soft tissue mass. CHONDROSARCOMA.
Fibrous ground glass appearance. FIBROUS DYSPLASIA
Periosteal reaction Infections/tumors. Takes 10-21 days to show. C
Periosteal reaction Subperosteal extension of blood, pus, or tumor. Caused by hyperemia, inflammation, and edema.
Sold periosteal reaction non-aggressive.
Laminated periosteal reaction Aggressive,layered or onion skinned.
Spiculated MOST AGGRESSIVE OF PERIOSTEAL REACTIONS hair-on-end or sunburst.
Sunburst even more aggressive then hair-on-end.
Codman's triange AGGRESSIVE: new bone at peripheral lesion-cortex junction.
Infectious lesions in soft tissue obliterate fascial plane lines.
Tumors displace fascial plane lines.
Soft tissue mass is smaller than the osseous lesion unless it started in soft tissue first.
Tumors normally stay out of joints.
Pigmented villonodular synovitis in joint
Cause boney erosions Degenerative cyst(geode), Rheumatoid arthritis, Gout, Pigmented Villondular synovitis
Standard Hip serives Frog leg lateral, and AP Pelvis.
Accessory view AP spot hip. Only done when there are questions for the AP Pelvis projection.
Frog leg pt makes a figure 4 with involved hip. Don't not use w/elderly.
Acetabular notch break in acetabular surface superomedially.
Sourcil(eyebrow) Bony condensation in the roof of the acetabulum.
Kohler's Teardrop not a true anatomical structure. Lateral border represents the anterior aspect of the acetabular fossa and its medial border the quadrilateral surface of innominate bone.
Inferior pubic rami are further apart and more horizontal in women.
The pubic symphysis should align w/ midline of sacrum
Kohler's teardrop and obturator foramen should be symmetric
Gluteal crease should overly the pubic symphysis in non-rotated pts.
Femoral Acetabular joint space Superior 3-6mmMedial 4-13mmAxial 3-7mm
Phleboliths below level of ischial spines. Seens after 30 yrs.
Injection depot Form if fat necrosis occurs after an injection.
Triradiate cartilage under 15 yrs. Represents growth centers of ischium, superior pubic rami, and ilium. Should fuse at 14 yrs. of
Ischiopubic Synchondrosis(Van Neck's Disease) Growth plates of pubic rami and ischium. Fuses between 4-8 yrs. Disappears around 16 yrs
Iliac spophysis(aka Iliac Epiphysis) Stages of ossification of the epiphysis indicates spinal maturity.(Risser's Sign)
Risser's Sign measurement of the progression of spinal maturity. Appears first laterally near ASIS and progresses medially to PSIS.
Rider's bone ASIS, ISCH TUBES, AIIS. Could be evulsion fractures.
Os acetabuli supeerolateral margin of the acetabular roof. Unrelated to roof of acetabulum
Paraglenoid sulcus m/c in females. Due to pressure of superior gluteal artery.
Pubic ears Extend inferiorly from pubic bone.
Vascular channels Y or v shaped grooves.
Bilarteral Iliac Horns congenital anomaly. AKA Nail patella syndrome, HOOD, Fong's or osteoonychodysplasia.
Nail Patella syndrome aka Bilarteral Iliac Horns, Fong's, HOOD Tetrad of dysplastic fingernails, hypoplastic or absent patellae, elbow dysplasias, and bilateral iliac horns. Osseous projections from the posterior iliac fossa
Herniation Pits aka Pitt's pits Erosions within the femoral neck. Have sclerotic margin. Should NOT be seen below INTERTROCHANTERIC LINE.
Femoral acetabular impingement inflammation caused by irregular joint capsules.
Wards Triangle. Inferior portion of femoral neck.
3 groups of trabeculae that form wards triangle Principal, secondary Compressive, and principal tensile group.
Obturator Internus fat plane inside of the pelvic brim just opposite to acetabulum. rare
Iliopsoas fat plane Medial to the femoral neck and extends toward the lesser trochanter.
Gluteus medius lateral to the capsular fat planes
Capsular fat plane just lateral to the femoral neck.
Pubic width Males 4.8-7.2mmFemales 3.8-6mm Never more than 10mm
Teardrop distance(medial joint space) Normal: 6-11mm with no more than 2mm difference side to side.
Waldenstron widening due to joint diffusion.
Femoral angle foot should be medially roated 15 degrees. Normal 120-130.
Less than 120 coxa vara
Greater than 130 Coxa valga
Center edge angle (CE angle of Wiberg) Vertical line thru center of femoral head. another is drawn trhought the upper acetabular margin. NORMAL 20-40 degrees.
<20 hip dysplasia, acetabular dysplasia, and DDH
Kohler's Line Drawn from pelvic brim to lateral obturator foramen. Normal: Medial acetabulum should fall lateral to this line
Protrusio acetabuli Medial acetabulum is located medial to Kohler's line. Dash board fracture
Shenton's Line Curved line along undersuface of the femoral neck and is continued along under the superior pubic rami. Normal: should be continuous
Skinner's Line thru and parallel to femoral shaft. Second line is drawn perpendicular to the first, thru the proximal aspect of the greater trochanter.
Skinner's line normal:fovea capitus should lie at or above the level to the 2nd line.
Klein's Line Line is drawn parallel and off the cortex of the lateral femoral neck.
Klein's line Line should overlap the femoral head equally on both sides. This line may be drawn on frog leg. Usually occurs in 13-15yr males that are overweight
Dysplasia of the hip Allows femor to dislocate superior and inferior . Occurs at birth.
Lateral migration of the femoral head is measured by Horizontal line of Hilgenreiner(Y-Y line)
Acetabular roof in infants 27.5
Upper limit of normal in acetabular roof is 30. A measurement stronger suggest acetabular dysplasia.
Proximal migration of femur measured by observing the shortening of the vertical distance from the femoral metaphysis to Hilgenreiner's line.
Shenton's line is drawn between the medial border of the neck of the femur and the superior border of the obturator foramen.
Standard knee series AP Knee, Lateral Knee, Tunnel Knee.
Accessory view Tangenital Patella(Sunrise patella); Bilateral AP weightbearing knees; Oblique Knee
Ap Knee 15 degrees of internal rotation of foot
Lateral Knee Bend knee 30-35degrees of flexion.
Tunnel knee 45 degree flexion
Femorotibial joint space should measure between 5-11mm
Tangential Patella used to delineate the medial and lateral patellofemoral joint space 45 caudad tube tilt
Medial femoral condyle is larger and rounder then its lateral counterpart
Distal Femoral Epiphysis 5mm at birth and has fringe like margins
Os cyamella Ossicle in popliteus tendon on Lateral side.
Hypoplastic and absent patella Normal ossification doesn't happen until 4 yrs. Assciated with Fong's
Bipartite Patella Superolateral aspect. Bilaterally 80% of the time
Posterior Femur Secondary to muscle pull of the gastrocs or adductor magnus.
Blumensaat's line dense white line representing the surface of the intercondylar notch.
Soft tissue suprapatellar tendon and infrapatellar ligament.
bursa not usually seen around knee
Harris' (Growth arrest) line Can see multiple w/severe Leukemia. Resolution of arrested growth. Appears as horizontal linear opacities. M/C in metaphyseal region of long bone.
Hoffa's Fat Pad infrapatellar fat pad. between inferior pole of the patella and the tibial plateaus.
Ludloff's patch Sector-shaped radiolucency in the anterior aspect of the distal femoral epiphysis. m/c 16 yrs old.
Patellar alta patellar ligament greater than 20% longer than patella.Results in improper quadraceps muscle action. Chondromalacia patella
Patella Baja Too low. JRA, Polio, and achondroplasia
Os Fabella sesamoid bone is located within the tendon of the lateral head of the gastroc or posterior to the lateral condyle of the femur. Seen after 15 and is bilateral 2/3-3/4. AP view.
Sinding Larsen johannsend syndrome just like osgood-schlater's but at inferior patellar pole.
Pellegrini-Steida Calcification of the Medial collateral ligament of the knee. Due to previous trauma.
Intercondylar notch Common site for intraarticular loose bodies to hide.
Medial Patellofemoral joint space shorter and more vertical than lateral
Lateral patellofemoral joint space longer and more horizontal than medial.
Patellar Tooth sign Enthesopathic degenerative change of anterior surface of patella. usually with loss of patellofemoral joint space.
Ankle series AP Ankle, Medial Oblique Ankle, Lateral Ankle.
Accessory view Ankle Inversion and eversion stress views.
Ap Ankle requires 15 degress of internal rotation and dorsiflexion.
Lateral Ankle achilles tendon- Kagers Triangle.
Tibial Plafind underside of distal tibia.
Anterior calliculi of medial malleolus is longer then the posterior.
Lateral malleolus is 1cm distal and 1cm posterior to the medial malleolus
Medial clear space 3-4mm
lateral clear space medial cortex of the lateral malleolus and the cortical surface to hf peroneal groove of the tibia. Should measure no more than 5mm or show a difference of 2mm when compared.
Medial Oblique view of the ankle important view in the assessment of the post-traumatic ankle for the detecting subtle fractures of the distal fibular, posterior tibia, talar dome, and the base of the 5th Metatarsal.
stress views should be taken 1 or 2 hrs of the injury under anesthesia.
Talus tilts 6-7 degrees but can up to 20 degrees.
Talar Beak osseous projection of the talar neck.
Calcaneal apophysis SEVER"S DISEASE looks fragmented and sclerotic, but not.
Tarsal Coalition Congential union(fibrous or osseous). Predisposed to degenerative arthrisit. M/C are the talocalcaneal and calcaneonavicular joints.
Os peroneum Adjacent to the cuboid
Os Tibiale Externum Just medial to the navicular
Os Trigonum Posterior the the ankle joint.
Os Supranavicular Superior to the navicular.
Created by: DixieDoll



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