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NBCE Part IV Xray

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

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
Created by: ringjrkl
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