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Irene Gold: Diagnostic Imaging

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Osteochondroma
Most common BBT of appendicular skeleton
Sessile or pedunculated (coat hanger exostosis/cauliflower like)
What are the two types of Osteochondromas?
Hereditary Multiple Exostosis
Multiple osteochondromas are called...
20% become malignant.
What complication can arise with Hereditary Multiple Exostosis?
Diaphyseal/metaphyseal location. Centrally located.
Simple bone cysts are found where?
Simple Bone Cysts
Associated with "fallen fragment" sign
Unicameral Cyst
Another name for simple bone cysts
Epiphyseal/metaphyseal location. Eccentrically located.
Anuerysmal bone cysts are found where?
<20
What age is at risk for simple bone cysts?
<20
What age is at risk for aneurysmal bone cysts?
Epiphyseal/metaphyseal, 20-40 years old.
Where can you find Giant Cell Tumors? What age gets them?
Giant Cell Tumor
Soap Bubble Appearance
Quasi-malignant.
20% of the time, Giant Cell Tumors are ____________________
Osteoid Osteoma and Brodie's Abscess
Night pain relieved by aspirin
Osteoid osteoma
Radiolucent central nidus with severe reactive sclerosis
Brodie's abscess
Appears like an osteoid osteoma.
Enchondroma
Most common BBT of the hand.
Ollier's disease
Multiple enchondromas are called...
Enchondroma
May have a stippled appearance.
10-50% rate of malignant degeneration
Ollier's disease is at what risk for what complication?
Enchondromas with soft tissue calcification
Maffucci's syndrome
Bone island' round or oblong radiopaque lesion
Enostoma
Multiple bone islands
Osteopoikilosis
Osteoblastoma
Most common BBT to affect neural arch.
Osteoma
Most common BBT to affect skull
Frontal sinuses. Best seen on caldwell projection.
Osteomas are most commonly found where in the skull? How are they best seen?
Monostotic form (70%) and polystotic form (30%)

A third type is recognized: Polystotic with endocrine abnormalities. Therefore, be on the look out for Cafe au lait spots with coast of maine appearance.
Types of Fibrous Dysplasia
Monostotic Fibrous Dysplasia
Displays "Rind Sign"
It is physiological resorption of normal bone replaced by fibrous tissue.
What is fibrous dysplasia? What can it cause?
Fibrous Dysplasia
Ground Glass Appearance
1. Scoliosis
2. Cervical Kyphosis
3. Vertebral body scalloping with IVF enlargement
4. Cafe au lait spots with the Coast of California appearance.
Symptoms/signs of Neurofibromatosis
Neurofibromatosis
Cafe au lait spots with the coast of california appearance.
Multiple Myeloma
Most common primary malignancy of bone
Multiple Myeloma
Punched out Lesions
1. M Spike on immunoElectroPhoresis
2. Reversal of Albumin/Globulin Ratio
3. Bence-Jones Proteinuria
4. Elevated ESR
What lab results for Multiple Myeloma
Metastatic disease
Most common malignant tumor of bone~
Lytic metastasis
Moth Eaten Appearance
Over 40
Lytic metastasis occurs in people who are how old?
Lytic metastasis of the skull
Swiss Cheese Appearance
Hodgkin's disease
Most common form of metastasis in ages 20-40
Hodgkin's disease

(though ivory white vertebrae can be a couple things including pagets)
Ivory white vertebrae with anterior body scalloping
Hodgkin's
Uni-lateral hilar lymphadenopathy seen on a PA chest view.
Blastic Metastasis
Ivory White Vertebrae
>50
What age gets pagets?
1. Lytic or destructive
2. Combined
3. Sclerotic
4. Malignant (osteosarcoma)
Stages of pagets
Paget's disease
Cortical thickening, picture frame vertebrae, coarsened trabeculae, bone expansion, bowing deformities.
Osteosarcoma
MC malignancy found in children
Chondrosarcoma and fibrosarcoma
Creates a Spiculated/Radiating/Sunburst periosteal reaction of bone
Ewing's Sarcoma occurs at the ages of 10-25 and is found diaphysis of long bones
Ewing's Sarcoma occurs at the ages of _______________ and is found __________________
Ewing's Sarcoma
Permeative lesion that causes a multi-paralleled onion skin (laminated) type of periosteal reaction.
Chordoma
Aberrant Notochodral cell tumor.
Most common: Sacrum
2nd MC: Skull
Chordoma is most commonly found in what two spots?
>40
What age gets Chordoma?
Rotatory Scoliosis: Spinouses deviate to concavity
Simple Scoliosis: Spinouses deviate to convexity
What are the two types of scoliosis?
Cobb's and Risser Ferguson's
Lines of mensuration in scoliosis?
Adjust and Monitor: Under 20 degrees
Send to Orthopedist for bracing: 20-40 degrees
Surgical Consultation: Over 40
Cardio-pulmonary compromise and DJD: Over 50
At what degrees do we do the following treatments for scoliosis?

Adjust and Monitor:
Send to Orthopedist for bracing:
Surgical Consultation:
Cardio-pulmonary compromise and DJD:
1. Risser's sign
2. Wrist Films
What two things do we use to monitor scoliosis?
Rheumatoid arthritis
Symmetrical distribution, bilateral uniform loss of joint space, rat bite erosions, pannus formation, DIP's are spared.
Atlanto-axial instability
What precaution do we need to take for RA patients?
Rheumatoid arthritis
Rat bite erosions
RA. Nodes in MCP.
Haygarth's Nodes
RA
Swan Neck and Boutonniere deformity
RA
Baker's cyst can be associated with what?
+RA Latex, +FANA, +ESR, +CRP, normocytic normochromic anemia
What labs are positive for RA?
Shiny Corner sign (early), bilateral marginal syndesmophytes, squaring of vertebral bodies, bamboo spine, dagger sign, trolley track sign, poker spine.
List as many radiographic signs as you can for patients with ankylosing spondylitis
+HLA B27 and +ESR
Lab results for Ankylosing spondylitis
Enteropathic Arthropathy
Identical to AS in the pelvis but with GI dysfunction
Males 20-50
What sex/age is at risk for psoriatic arthritis
Psoriatic arthritis
Cocktail sausage digits, pitted nails, silver scaly lesions on extensors.
Increase in joint space, mouse ear deformity, pencil in cup deformity, ray sign, atlanto-axial instability, non-marginal syndesmophytes in the spine.
List as many radiographic signs as you can for psoriatic arthritis
Reiter's
calcaneal spur, fluffy periostitis, non-marginal syndesmophyes in the spine.
Marginal: Ankylosing spondylitis and enteropathic arthritis
Non-Marginal: Psoriatic Arthritis and Reiter's
Ankylosing Spondylitis, Rheumatoid arthritis, Enteropathic arthropathy, Reiter's (Reactive Arthritis), and psoriatic arthritis.

Tell me which ones have marginal syndesmophyets and which have non-marginal syndesmophytes.
SLE
Can cause ulnar deviation of phalanges with no joint destruction.
SLE
Positive Rebound Effect
+LE Prep, +FANA, +RA Latex, +ESR, leukopenia, Thrombocytopenia.
Labs for SLE
SLE
Sunlight precipitates a skin rash, oral ulcers, and alopecia. Raynaud's phenomenon can be present.
Scleroderma
Associated with distal tufts of phalanges and with CREST syndrome.
Females 30-50
What sex/age gets Scleroderma?
Multi-parous females, 20-40 yo.
Who is at risk for Osteitis Condensans Ilia?
Osteitis Condensans Ilia
Bilateral/symmetrical triangular sclerotic areas on lower half of ilium. Normal joint space.
Self resolving. Manage with trochanteric belt for stability
How do we treat Osteitis Condensans Ilia?
C5/C6
Most common site affected by DJD complications is....
Nodes in the DIP associated with DJD.
Herberden's Nodes
Decreased superolateral joint space with sclerosis.
What does DJD look like in hip?
Decreased medial joint space with lateral space preserved.
What does DJD look like in the knee?
DISH/Forestier's disease
Another name for Diffuse Idiopathic Hyperostosis
DISH
Male. 40yo. Neck stiffness and/or pain with swallowing.
Diabetes Mellitus
DISH is associated with what systemic condition?
Flowing Hyperostosis, candle wax drippings, 4 continguous segments involved, disc space preserved.

Calcification of the PLL (OPLL)
What are the radiographic findings for Forestiers?
Neurogenic Arthropathy. Secondary to impaired sensory function in joints.
Charcot's Joint
Diabetes, tabes dorsalis, syphilis, syringomyelia
Neurogenic Arthropathy is most commonly seen with what conditions?
Distension, density of subchondral sclerosis, debris within joint, dislocation, disorganization, and destruction of bone
6 D's msot common in weight bearing joints.
Knee. Result is multiple loose bodies within the joint that are round or ovoid in shape.
Synoviochondrometaphasia most commonyl affects what joint? What is the result?
Gout in big toe
Podagra
Gout
Tophi Crystals
Gout
Overhanging margin; juxta-articular erosions.
Pseudo gout. Thin linear calcification parallel to the articular cortex within joint space. Called chondrocalcinosis when affecting cartilage. Most common in knee.
Calcium Pyrophosphate Dihydrate Crystal Deposition Disease (CPPD)
Round or oval calcifications near the insertion of a bursa or tendon.
Hydroxyapatite Deposition Disease (HADD)
Shoulder
HADD most commonly affects what joint?
Avascular necrosis. They are all self resolving but it takes 8 months to 2 years.
How do we treat AVN?
DJD
All AVN's can lead to ....
Trauma
MC cause of AVN
Carpal Scaphoid
Location for preiser's AVN
Femoral epiphysis
Location for legg calve perthes
Tarsal navicular
Location for kohler's AVN
Calcaneous
Location for sever's AVN
Medial Tibial Condyle
Location for Blount's AVN
Head of 2nd or 3rd metatarsal
Location for Freiberg's AVN
Articular surface of medial femoral condyle
Location for Osteochondritis Dessicans
Capitellum
Location for panner's AVN
16-25 year old athletes
Who gets Osteochondritis Dessicans
Osteochondritis Dessicans
Knee locks in extension; Wilson's sign
On a tunnel view radiograph
Osteochondritis Dessicans is best seen...
Scheuermanns
Young, rounding shoulders, kyphosis, back pain.
1. Slight off of anterior body height of one or more vertebrae (10-15%)
2. Multiple endplate irregularities of 3 or more continuous vertebrae
Radiographic signs for scheuermons disease
Thoracolumbar brace; strengthen the erectors and stretch the pecs.
How do we manage Scheuermann's disease
Legg Calves Perthes
AVN of the femoral head.
Boys 4-9
What age/sex gets Legg Calves Perthe?
Mushroom capped appearance
Healed LCP gives what radiographic appearance?
Legg Calves Perthes disease
Refer to orthopedist for an "A" brace
Slipped capital femoral epiphysis
Femoral head slides inferior and medial/femoral neck slides superior and lateral
Boys 10-16
What age/sex gets slipped capital femoral epiphysis?
Klein's, Shenton's, Skinner's
What lines are helpful when assessing Slipped Capital Femoral Epiphysis
Congenital hip dyplasia. Triad is:
1. Hypolastic femoral head
2. Shallow acetabular shelf
3. Femoral head outside acetabulum
Putti's Triad
Axial migration of the femoral head with uniform loss of joint space
Protrusio Acetabuli
RA (but can happen with any disease like osteopetrosis, paget's, etc)
Bilateral Protrusio acetabuli most often occurs wiht what disease?
Kohler's
What lines do we use to measure Protrusio Acetabuli?
Avulsion fracture
Portion of bone torn away by muscle or ligament tractional force
Comminuted
A fracture with more than two fragments.
Diastasis
Displacement or separation of a slightly moveable joint
Compound/open fracture
Skin ruptured and bone exposed
Greenstick/hickory stick fracture
incomplete fracture in children
Impaction fracture
Bone fragments driven into one another
Torus/Buckling Fracture
Incomplete fracture, one side of cortex affected
Occult fracture
Clinically evident but not seen on x-ray.
Fatigue/stress fracture
Insufficiency or repetitive stress causes the fracture
Bennett's
Fracture of 1st metacarpal
Boxer's
fracture of 2nd or 3rd metacarapal
bar room
Fracture of 4th or 5th metacarpal
Scaphoid
Most commonly fractured carpal bone
Nightstick
Fracture of proximal ulna
Monteggia
Fractured ulna with radial head displacement
Galeazzi
Fracture of distal 1/3 of radius with displacement of distal radio-ulnar joint
Smith's
Fracture of distal radius with posterior displacement of the distal fracture.
March
Stress fracture of the 2nd, 3rd, or 4th metatarsals
Jones
Transverse fracture at proximal fifth metatarsal
Clay Shovelers
Avulsion fracture of spinous process
Hangmans
Bilateral pedicle fractures of C2 due to hyper-extension injury
Fractures through anterior and posterior arches of atlas due to axial compression
Jefferson Bursting
Type 1: Avulsion of tip of dens
Type 2: Fracture at the base of the dens
Type 3 Fracture through body of C2
Odontoid fractures types
Teardrop
Avulsion of the anterior inferior aspect of VB from a hyperextension trauma
C2
Most common site of teardrop Fracture
Types
1. Horizontal fracture through growth plate
2. Growth plate and metaphysis (most common)
3. Growth plate and epiphysis
4. Growth plate, metaphysis, and epiphysis
5. Compression deformity of growth plate (most severe)
Salter Harris Types
Osgood Schlatters
Tibial apophysitis
Osgood Schlatters
Use cho-pat brace
Rider's bone
Avulsion of ischial tuberosity
Chance Fracture (seatbelt)
Horziontal fracture through single body and posterior arch
Spondylolysis
Fracture through pars interarticularis without slippage
1. Dysplasia (congenital)
2. Isthmic (fx through pars)
3. Degenerative (DJD of joinnt facet)
4. Traumatic (fx through pedicle)
5. Pathological
Types of Spondylolisthessis
Flexion/extension to assess for stability
A patient has a spondy. What radiographs do we want to take?
Lunate
Most commonly dislocated carpal bone
Dislocated lunate
Pie Sign
Dislocated scaphoid
Terry Thomas sign
Dislocated scaphoid
Signet ring sign
Superior labrum anterior to posterior. It is a glenohumeral tear.
SLAP lesion
Posterior Ponticle
Arcuate foramen forms when atlanto-occipital ligament calcifies. Transmits sub-occipital nerv eand vertebral artery
20% are born without transverse ligaments. MUST perform stress films before we can treat them.
What contraindication to adjusting is present with a down's syndrome patient?
Os Odontoideum
Dens is not fused with C2 body
Congenital block
Adjacent vertebra osseously fused from birth
Congenital block
Wasp waist and hyplastic disc
Klippel-Feil Syndrome
Multiple congenital blocks
Short webbed neck, low hair line, and decreased ROM
How do patients with Klippel-feil present
Sprengle's deformity and omovertebral bone
Klippel-Feil syndrome is associated with what other two deformities?
Butterfly vertebrae
Failure of center of VB to ossify properly
Hemivertebrae
Failure of development of lateral ossification center.
Hemivertebrae
Isolated wedge vertebrae causing a scoliosis
Spina Bifida
Failure of lamina to fuse. Elevated alpha fetoprotein and folic acid deficiency
Asymmetrical articular planes
Facet Tropism
Knife clasp syndrome (pain with extension)
Spina bifida of S1 with L5 spinous enlargement
Less than 120 coxa-femoral angle.
Coxa Vera
Greater than 130 coxa-femoral angle
Coxa Valga
Mikulicz's line
What line is used to measure Coxa vera and Valga?
Magelung's deformity
Shortened distal radius, asymmetrical prominence of ulnar styloid, posterior subluxation of distal ulna.
Calcification of medial collateral ligament
Pelligrini Steida
Calcification of muscle belly. MC in biceps and quads.
Myostitis Ossificans
Distal to renal arteries
MC location for an abnormal aortic aneurysm?
Aortic dilation, curvilinear calcification, fusiform appereance.
Radiographic signs of an AAA?
Radial head fracture.
Fad pads in the elbow seen on lateral view indicate....
Sickle Cell Anemia
Hair on end appereance in skull.
Collapse of vasculature. Seen in sickle cell anemia.
H shapes vertebrae in the spine.
Thalassemia
Another name for Cooley's anemia
Hereditary disorder of hemoglobin synthesis (microcytic hypochromic anemia)
Thalassemia
Widened Epiphysis (Seen in thalassemia)
Erlenmeyer Flask Deformity
Hyperarathyroidism
Brown Tumors
Hyperparathyroidism
Salt and Pepper Skull
Hyperparathyroidism
Rugger-Jersey Spine
Early: Bone within bone
Late: Sandwich vertebrae
What radiographic signs do we see for osteopetrosis late and early?
Rickets
paintbrush metaphysis
Muscle tetany, weakness, and bone deformity.
Symptoms of rickets
Landmarks: from nasion to center of sella turcica. Then, from basion (anterior foramen magnum) to center of sella turcica.
Significance: If angle is >152 degrees, indicates platybasia which may be associated with basilar impression.
Basilar Angle (Martin's Basilar Angle)

Landmarks:
Significance:
Landmarks: From hard palate to base of occiput
Significance: If odontoid is >8mm above this line in males or >10mm above in females, indicates basilar impression.

This is most accurate line for basilar impression
McGregor's Line

Landmarks:
Significance:
Landmarks: Hard palate to opishtion (posterior foramen magnum)
Significance: If odontoid is >7mm above this line, indicates basilar impression.
Chamberlin's line

Landmarks:
Significance:
Landmarks: Anterior foramen magnum (basion) to posterior foramen magnum (opisthion).
Significance: If occipital bone is above the line, this indicates basilar impression.
Macrae's Line

Landmarks:
Significance:
Landmarks: C1 Anterior tubercle to the odontoid
Significance: If this space is >3mm in adults or >5mm in children, this indicates transverse ligament rupture or instability due to trauma, down's syndrome, or inflammatory arthritis.
Atlantodental interspace

Landmarks:
Significance:
Landmarks: Lines drawn at each spinolaminar djunction should form a smooth arc-like curve.
Significance: Discontinued line may indicate A to P vertebral malposition like anterolisthesis or retrolisthesis.
Posterior Cervical Line

Landmarks:
Significance:
Landmarks: Lines drawn at posterior bodies of C2 and C7
Significance: Flexion should intersect at C5/C6. Extension should intersect at C4/C5. may be altered by muscle spasms, joint fixation, or disc degeneration.
Stress lines at cervical spine

Landmarks:
Significance:
Landmarks: Anterior Vb to posterior margin of air shadow of pharynx, larynx, and trachea
Significance: The following is indicative of a soft tissue mass.
- Retropharyngeal (C2-4): >7mm
- Retrolaryngeal (C5): >14mm
-Retrotracheal (C6-7): >22mm
Prevertebral Soft Tissues

Landmarks:
Significance:
Landmarks: Locate superior and inferior extremes of scoliosis. Draw parallel line through superior endplate of extreme superior vertebra and through inferior end plate of extreme inferior vertebra. Intersecting perpendicular lines are drawn and angle is measured.
Significance: Scoliosis Evaluation
Cobb's Method of scoliosis Evaluation

Landmarks:
Significance:
Landmarks: Locate superior and inferior extremes of scoliosis and apical segment. Diagonal lines are drawn to locate the center of the VB. Two lines are drawn connecting center of apical segment with each end vertebra and resultant angle is measured.
Significance: Scoliosis evaluation. Values are 25% below Cobb method of evaluation.
Risser-Ferguson Method of Scoliosis Evaluation

Landmarks:
Significance:
Landmarks: Tangential line of drawn parallel and through posterior margin of S1 and vertical line is draw intersecting the sacral line.
Significance: Normal angle 30-72 degrees. Average angle is 46 degrees.
Sacral Inclination

Landmarks:
Significance:
Also called Ferguson's angle or sacral base angle.

Landmarks: Oblique line drawn through and parallel to the sacral base. Horizontal line parallel to the bottom edge of the film
Significance: Normal angle: 26-57 degrees. Average angle 41 degrees
Lumbosacral Angle

Landmarks:
Significance:
Landmarks: Sacral base divided into quarters and relative position of the inferior aspect of L5 is made.
Significance: Determines the degree of anterolisthesis.
Meyerding's Grading method of spondylolisthesis

Landmarks:
Significance:
Landmarks: Line drawn parallel and through the sacral base. Perpendicular line drawn from the sacral promontory.
Significance: L5 is beyond the perpendicular line: Spondylolisthesis.
Ullmann's Line

Landmarks:
Significance:
Landmarks: Line drawn to connect the tops of the superior and inferior articular processes. The distance to posterior body margin at the midpoint is measured.
Significance: Measurement <15mm: Spinal canal stenosis.
Eisentein's Method for Sagittal canal measurement.

Landmarks:
Significance:
Landmarks: 4 landmarks are drawn.
1: Interpendicular distance
2: Sagittal canal dimension (eisenstein's method)
3: Transverse body dimension
4: Sagittal body dimension
Significance: Ratio 1x2/3x4. THe higher the ratio the smaller the canal. If >1:6 at L3, L4, or 1:6.5 at L5, canal stenosis is indicated.
Canal/Body Ratio

Landmarks:
Significance:
Landmarks: Lines are drawn parallel and through the inferior end plate of L5 and superior end plate of S1.
Significance: Normal: 10-15
Lumbosacral disc angle

Landmarks:
Significance:
Also called Ferguson's line.

Landmarks: Vertical line is drawn through the center of the L3 vertebral body.
Significance: Lines should intersect at sacral base. If line anterior: possible hyperlordosis. If line posterior to sacrum: Possible hypolordosis.
Lumbar Gravity Line

Landmarks:
Significance:
Landmarks: A line is drawn parallel and through the inferior end plate
Significance: If line intersects the superior articular process of the vertebra below, extension malposition or face imbrication is suspected.
Macnab's Line

Landmarks:
Significance:
Landmarks: Curvilinear line is drawn along the inferior aspect of the TP, the inferior articular process, and through the joint space to the superior articular process of the vertebral below.
Significance: Should be a smooth "S" shaped curve. An interruption in the S curve indicates subluxation or facet imbrication.
Hadley's "S" Curve

Landmarks:
Significance:
Landmarks: A line is drawn along the pelvic inlet to the outer aspect of the obturator foramen.
Significance: If acetabular floor crosses the line, this indicates protrusio acetabuli.
Kohler's Line

Landmarks:
Significance:
Landmarks: A smooth curvilinear line is drawn along the inferior femoral neck to the superior aspect of the obturator foramen.
Significance: An interrupted, discontinuous line indicates dislocation, neck fracture, or slipped capital femoral epiphysis.
Shenton's Line

Landmarks:
Significance:
Landmarks: A smooth curvilinear line is drawn along the outer ilium, across the joint, and onto the femoral neck.
Significance: Bilateral asymmetry indicates a slipped femoral capital epiphysis, dislocation, fracture, or dysplasia.
Iliofemoral Line

Landmarks:
Significance:
Landmarks: Two lines are drawn through and parallel to the mid-axis of the femoral shaft and the femoral angle.
Significance: Normal Angle is 120-130. <120 its coxa vera. >130 its coxa valga
Femoral Angle (Mikulicz's Angle)

Landmarks:
Significance:
Landmarks: A line is drawn through and parallel to the femoral shaft. A perpendicular line is drawn tangential to the tip of the greater trochanter.
Significance: A fovea capitus should lie above or at the level of the trochanter line. If the fovea capitus falls below this line, it indicates fracture or coxa vara.
Skinner's Line

Landmarks:
Significance:
Landmarks: A line drawn along the outer margin of the femoral neck.
Significance: The femoral head should intersect the line. Failure to intersect the line indicates a slipped capital femoral epiphysis.
Klein's Line

Landmarks:
Significance:
Landmarks: A line is drawn between the superior and inferior patellar pole. A line is drawn between the inferior patellar pole and the tibial tubercle.
Significance: Patellar length and patellar tendon length should be approximately equal. If the tendon length is 20% greater than the patellar length, this indicates patella alta.
Patellar Position

Landmarks:
Significance:
Landmarks: Shortest distance is measured between the plantar surface of the calcaneus and the external skin contour.
Significance: If this distance is >25mm in a male or >23mm in a female, this signifies increased thickness often associated with acromegaly.
Heel Pad Measurement

Landmarks:
Significance:
Landmarks: Three highest points on superior aspect of calcaneus are connected with two lines.
Significance: If the resultant angle is < 28 degrees, this indicates calcaneal fracture or dysplastic calcaneus.
Boehler's Angle

Landmarks:
Significance: