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NBCE Part IV Xray
Anything and everything you need to know about NBCE Part IV Xray in Study Stack
| Question | Answer |
|---|---|
| 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 | AS |
| 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 | c2 |
| 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 | PP |
| 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 | fx |
| 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 | fx |
| Thick radiolucent line through base of dens | OO |
| 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 | T1 |
| 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 | c4 |
| 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 | MM |
| 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 | fx |
| Displacement of LS pedicle | fx |
| 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 | AS |
| 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 |
| 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 | mm |
| 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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