TERMS: - Weebly



TERMS:

Osteopenia – reduced bone mass; decreased bone density.

Radiolucent – clear to X-ray photography (appears black).

Radiopaque – X-ray dense or absorbed (appears white from X-ray absorption).

Cortical bone, trabecular bone, muscle, water, air, fat

Contrast (image) – differentiation, generally in black and white. High contrast = reduced grayscale.

Differential absorption – different absorption properties of different materials based on atomic properties.

Contrast (i.e. oral, bronchogram, angiography [arteriograms and venograms], arthrogram, air-sinogram) – foreign substance introduced to the body that yields high contrast radiography.

Metastasis – beyond stasis; malignant cancer or infection.

DESCRIBE TYPES OF BONE DEVELOPMENT:

Intramembranous and enchondral.

Intramembranous – primarily flat bones (facial, calvaria, ilia). Periosteal tissue maintains bone via periosteum and endosteum. Bone repair following fracture ensues via this method.

Enchondral – classic manner of long bone formation; formed in chondral tissue.

Hematopoietic sites in a:

Child: bones (all). Necessary for growth and development.

Adult: ends of the longs bones (metastasis) and flat bone (pelvis, sternum, ribs, and spine).

Geriatric: Reduced to smaller areas of the metastases and spine, ribs, ilium)

Draw a femur and label the parts:

Greater trochanter

Lesser trochanter

Shaft

Neck

Head

Fovia capitis

Medial condyle

Lateral condyle

Medial epicondyle

Lateral epicondyle

Linea aspira

Nutrient foramen

Growth plates

Intertrochanteric line

Epiphysis

Metaphysis

Periosteum

Cortex

Why do we use X-ray?

Proper use of X-ray is for attempting to document the differential or confirm a diagnosis:

Trauma

Mammography or other familial disease

Review of systems

When do we use radiology?

General procedure for a patient:

Paperwork

Interview and consultation

History (LOPPQqRSTTxB)

Inspection and PE

Palpation

Percussion

Instrumentation

ROM

Orthopedic

Neurologic

Document clinical findings and derive a differential diagnosis

Appropriate time for report of findings, or release the patient, or accept the person as a patient with contractual obligations.

E X-ray

Lab

There are exceptions to following the above protocol.

Documentation:

Liability:

GP read all films – held as specialist in X-ray in court.

GP reads some films and sends others - held as specialist in X-ray in court.

GP sends all – GP liability only.

Basically, this translates to only two levels of liability.

Chiropractic radiologists 71.00

Skeletal radiologists and fellows 70.18

Chiropractic radiology residents 61.54

General medical radiologists 51.64

Medical radiology residents 44.64

Medical clinicians 31.26

Chiropractic clinicians 28.38

Chiropractic students 20.45

Medical students 05.

Rule in, rule out, or monitor a know condition all with proper documentation is purpose for taking X-ray.

It is easy to sue for low initial court filing costs. Some recommend that you not let a patient’s bill get over $200. Much of what we learn has design to protect against legal suits. Often it is more profitable to outsource as much as possible to reduce liability.

HOW DO WE COMMUNICATE THE RESULTS:

The X-ray report has design to verbally communicate the X-ray status.

Useful to communicate between doctors and offices.

To allow investigation by other specialists.

X-ray report is satisfactory replacement of X-ray film.

Attorneys need reports to make a case.

Workers Comp and Insurance have reviews for reimbursement.

The patient pays for the information derived from the X-ray but not the X-ray itself. Additionally, the doctor has legal obligation to maintain the X-ray records.

INFORMATION ON AN X-ray REPORT:

I. Imaging center (who is interpreting the report).

II. Patient information (who, age, DOB).

III. Radiographic information (date of exam, series, technique [mA x time x kVp] optional - normally in a logbook).

IV. Body of report: generic, descriptive, in the fewest words possible (with use of “buzzwords”).

V. Impressions: interpretation noted (differential diagnosis from most important to least important).

VI. Recommendation/comment (optional) – Dr. Kuhn says to rarely use this part.

IMAGING TOOLS AVAILABLE

Know about the study, cost, and what it will do or not do.

Have the ability to communicate the method to a patient.

Imaging tools

• Plain film

• Myelography

• Computerized tomography

• Helical Computerized tomography

• MRI

• Bone scan

• SPECT

Plain film – Wilhelm Conrad Roentgen (11/8/1895)

Strengths: availability, relatively low cost, well known usage.

Weaknesses: ionizing radiation, relatively poor resolution, poor spatial localization, soft tissues generally not seen.

Proper use: introductory study, can evaluate IVF well, use to rule out contraindications for advanced imaging, not good for central canal stenosis.

Conventional tomography – largely replaced by CT.

1. Linear.

2. Circular.

3. Elliptical.

4. Hypocycloidal.

5. Trispiral.

Myelography

Production: utilizes ionizing radiation, depends on displacement of contrast column, differential absorption.

- air was the first contrast agent used. Other materials include poppy seed oil, pantopaque. In the 1940’s water soluble products (very toxic). 1970 metrizamide non-ionic, water soluble, in use today.

Complications: arachnoiditis, infections, arterial bleeding, headache is the most common complication.

Proper use:

Disc herniation – sharp angular indentation on the thecal sac, decreased IVD, enlargement of a nerve root sleeve secondary to edema, displacement of non-filling of a root sleeve.

If CT or MR are not available

Patient who cannot undergo MRI because of time, size, claustrophobia, other contra-indications

May be used in conjunction with CT.

Weakness: more expensive than MRI, ionizing radiation, relatively poor resolution, soft tissues not well seen, high rate of false negatives, potential complications from contrast agent.

Strengths: relatively good availability, good cost benefit ratio, well known utilization.

Computerized Tomography:

Technical aspects: ionizing radiation, absorption differentials, computer generated pictures, Hounsfield unit, pixels, voxels, volume averaging, slice thickness scout films. Best thing it does is axial imaging.

Strengths: widely available, improved visualization of soft tissues, can provide three dimensional imaging, accurately measure a variety of structures, image manipulation possible. Only 1-3 percent change in bone density will show up on CT. Allows for a change in parameters to view different level(s) and window(s).

Weaknesses: higher cost than plain film and lower than cost MRI, ionizing radiation, intracranial artifacts, artifacts secondary to metallic implants, dose is a consideration.

Proper use: very good axial images, excellent bone detail, some application in the neurology work-up.

Vacuum phenomena – air trapped in what was nucleus pulposis.

Vacuum cleft – air trapped in what was the annulus fibrosis.

Helical computerized tomography:

CT donut spins and patient continually moves through the scanner.

Throughput time and image quality improved.

Produces a higher density of data.

MRI:

Technical aspects:

- MRI technologies developed from nuclear resonance used to evaluate chemical composition of laboratory samples.

- Raymond Damadin first produced a full body MRI in 1976.

Equipment:

- gantry contains one of three types of magnets.

1. super conducting magnet – primary magnetic coils super cooled

2. permanent magnets – open magnetic resonance utilizes this type of magnetic reducing claustrophobic affects. Cannot achieve the high field strength of super conducting magnet. High noise to signal ratio. Improved software improved these images.

3. Resistive electromagnets – classic electromagnet, low initial cost, lower in weight, very high power consumption – may consume savings in the long run.

Functional MRI requires a BIG magnet, super-cooled.

Claustrophobia is the number one reason for failure. There are reports that the contrast material irritates this situation.

Magnetic resonance gradient magnetic coils:

• located within the gantry

• allow “slicing” of the patient’s anatomy

• along sagittal, coronal, or axial planes

• rapid on/off switching

• produces the loud clicks and taps heard by the patient.

Radiofrequency (RF) coils:

• placed on or near the area of interest

• used to excite target tissue

• also receives information regarding hydrogen nuclei relaxation

Image production

• hydrogen is a charged particle representing 80% of all the atoms in the body

• hydrogen behaves like a small bar magnet

• they are randomly oriented and their charges cancel out

• the MR scanner can spatially locate hydrogen within the body

• in the strong magnetic field of the MR unit, the hydrogen molecules tend to align with (or less often against) the field.

• The hydrogen molecules are not held static, but are induced to demonstrate precession (wobble)

• They are aligned, but they precess or spin out of phase

• A strict linear relationship exists between the frequency of precession and the MR magnetic field.

• Energy must be added to the system. RF identical to the Larmor frequency is pulsed into the patient. This is the concept of resonance. This causes the aligned hydrogen atoms to precess in phase. The RF pulse is turned off in the “excited” hydrogen atoms undergo “relaxation”.

Spin Echo Sequence

The appearance of the image reflects the intensity of the emitted signal. High signal intensity appears bright and dark areas represent areas of low signal intensity.

Intensity of the signal is determined by the quantity of mobile hydrogens and two magnetic relaxation times. T1 AND T2.

Manipulating the repetition of administered RF pulses (repetition time, TR) and collection of the emitted RF signal (echo time, TE) influences the image characteristics. Images may be described as proton density in which the image is based on the population of hydrogen T1-weighted or T2-weighted

MR PULSING SEQUENCES

WEIGHTING TR TE

PROTON LONG SHORT

T1 SHORT SHORT

T LONG LONG

T1 protocols utilized

• TR’s of 200-500 milliseconds approximately

• TE’s lasting approximately 15 milliseconds

• T2 images are very tiny consuming protocols and have long TR’s and long TE’s

• Hybrid images have been developed to take advantage of T2 type images with greater economy of time

Imaging protocol in MRI

• the parameters selected usually represent a compromise between radiologist preference, diagnostic capability and examination time.

• Differential considerations greatly affects image sequence selection

• Extradural disease represents the most common diagnostic request.

T1-spin echo

• essential to exam the spine; exams anatomy, marrow space, sagittal gradient echo.

Intramedullary disease

MRI – CONTRAST

• non-iodinated: adverse reactions very rare

• magnetic contrast agents

• gadolinium is the most common agent

- works as a T1 shortening agent which causes tissue containing gadolinium to appear bright on T1

- very useful in cases of:

• CNS tumor

• MS

• disc herniation versus scar tissue

MRI STRENGTHS

• superior resolution

• superior tissue contrast

• images soft tissue very well

• non-contrast enhancement in the spinal canal

• axial images OK

• coronal, sagittal, etc. images are superior

• MRA can produce non-contrast visualization of major and minor vessels

• Measurements may be accomplished

• MR reports on the physiology as well as anatomy

• Not reliant on attenuation of ionizing radiation

• No known harmful effects

MRI WEAKNESSES

• time and money

• cannot manipulate the image

• if the MR scanner is no sequenced correctly, information may be lost or hidden

• high resolution MR bone detail is adequate and on standard MR images, bone detail is poor

MRI CONTRAINDICATIONS

• pace makers, ear implants, miscellaneous implanted electronic devices, cerebrovascular clips, machine shop workers, claustrophobia, orthopedic implants (distorts gaussian field)

FMR – functional MR; most recent work to map brain activity or functionality.

BONE SCAN

1. Injection of a radioactive isotope (technetium)

2. Uses a gamma camera or scintilla scope to view osteoblastic activity as demonstrated by technetium uptake.

SPECT/PET SCAN (Single Photon Emission CT/Positron Emitted Tomography)

SPECT is to bone scan as CT is to plain film.

PET utilizes uptake of glucose to generate pictures.

COLOR-DUPLEX SONOGRAPHY OF THE ARTERIES

Can measure the amount of occlusion.

Basic anatomy and physiology review.

Apophysis – a bump on a bone that has/had a growth plate but no articular cartilage (greater/lesser trochanter).

Calcium and phosphorous. Calcium is in use for clotting, contraction, conduction; parathormone regulates blood calcium level and is in a 2:1 ratio with phosphorous (Ca:P). Acid phosphatase (break-down) and alkaline phosphatase (build-up).

Calcium: phosphorous allows Ca to complex into the bone matrix. Parathormone releases with low serum Ca; this allows improved complexing of Ca in serum through the vitamin D loop. There are normal levels of parathormone required. Calcitonin: (unknown where, specifically, it produces) inhibits serum level increases of Ca. Estrogen and androgens control growth as does products of anterior pituitary (growth hormone). Short lecture on acromegaly, dwarfism, etc. Glucocorticoids released in response to certain stresses and can lead to bone loss.

MENSURATION

| | |Average |Min |Max | |

|Sella turcica size |Horizontal : widest diameter |11mm |5mm |16mm |Pituitary and extrapituitary masses enlarge the |

| |Vertical: fossa floor to clinoids |8mm |4mm |12mm |fossa |

|Basilar angle |Nasion – center sella turcica |137( |123( |152( |Basilar impression and platybasia widen the angle.|

|(Martin’s, Welcker’s, |Basion – center sella turcica | | | |Yokum uses 1( (congenital; fusion) and 2( |

|spenobasilar ) | | | | |(acquired; Paget’s, osteomalacia, fibrous |

| | | | | |dysplasia) |

|Chamberlain’s line – |Hard palate – opisthion (difficult to |Below line to | |7mm |Basilar impression when odontoid more than maximum|

|know this enough to |see without high kVp/mAs technique) |3mm above | | |distance above. (Paget’s, osteomalacia, etc.) |

|not use this | | | | | |

|McGregor’s line |Hard palate – occiput. Note relative |Below line | |Males 8mm |Basilar impression when odontoid more than maximum|

| |odontoid apex. | | |Females 10mm|distance above. (Paget’s, osteomalacia, etc.) |

|Digastric line |Right and left digastric grooves: |11mm |1mm |21mm |Basilar impression when odontoid is above the |

| |line-odontoid distance | |(odontoid | |line. |

| |line-C1/OCC joint distance | |not above | | |

| | | |the line) | | |

|ADI |C1 anterior tubercle – odontoid |Adult |1mm |3mm |Transverse ligament rupture or instability. |

| | |Child |1mm |5mm |Trauma, Down’s, occipitalization of atlas, etc. |

| | | | | |and inflammatory arthritis may increase ADI. ADI |

| | | | | |should not gap at all in flexion/extension. |

|George’s line |Alignment of posterior body margins |Aligned | | |A to P vertebral malpositions when line not |

| | | | | |smooth; traumatic, >2mm suspect instability |

| | | | | |(ligament laxity). |

|Posterior cervical |Spinolaminar junction lines |Aligned | | |A to P vertebral malpositions when line is not |

|line – more often | | | | |smooth, especially at C1 and C2; used in |

|spinolaminar line | | | | |conjunction with George’s line for spinal canal |

| | | | | |stenosis (when less than 12mm). |

|Sagittal canal |Posterior body – spinolaminar junction | |12mm | |Spinal stenosis when less than 12mm. Intraspinal |

|dimension – know that |lines | | | |tumor when enlarged |

|it doesn’t work | | | | | |

|Atlantoaxial alignment|C1 lateral mass – C2 articular pillar |Aligned | | |Jefferson’s or odontoid fractures or alar ligament|

|(rotation) |margin alignment | | | |instability when margins overlap. If C1 articular |

| | | | | |mass slides more than 2mm over C2, suspect |

| | | | | |fracture [with 5( suspect dens fracture, 7( |

| | | | | |confirmed dens fracture]. |

|Cervical gravity line |Vertical line from odontoid apex |Passes through | | |AP displacement is a gross indicator of |

| | |C7 body | | |gravitational stress at the cervicothoracic |

| | | | | |junction. |

|Lordosis or angle of |Line from inferior endplates of C7; |40( |35( |45( |Role unclear. Decreased following trauma, muscle |

|C-spine |line through anterior and posterior | | | |spasm, spondylosis, and patient tucking the chin |

| |tubercles of C1; take perpendicular | | | |at time of exposure |

| |lines from each above to obtain angle | | | | |

|Retropharyngeal space |Posterior margin of pharynx and | | | |7mm - 20mm considered normal |

| |anterior margin of spine | | | |C5, Pharynx above is 7 |

| | | | | |Trachea below is 20 |

| | | | | |Enlargement often from pus, blood, cells |

|Cobb’s angle |most inferior endplate of lowest | | | |Scoliosis named for the side (levo or dextro) and |

| |vertebra for first horizontal line, and| | | |degree at any level. 10( or more is a scoliotic |

| |superior endplate of highest vertebra | | | |curve, less is a convexity. |

| |for second horizontal line; | | | | |

| |perpendicular lines form each form an | | | | |

| |angle | | | | |

|Risser-Ferguson |Centers of end and apical segments | | | |Scoliosis evaluation – this method demands that a |

| |joined and the angle measured | | | |vertebra is a apex or base. |

|Thoracic kyphosis |T1 superior endplate – T12 inferior | | | |Kyphosis evaluation – often presents with abnormal|

|(straight back |endplate, then intersecting | | | |cardiac sounds. |

|syndrome) |perpendiculars and the angle measured | | | | |

|Thoracic cage |Posterior sternum – anterior T8 body |Male 14cm |11cm |18cm |Straight back syndrome when the distance is less |

|dimension | |Female 12cm |9cm |15cm |than 13 cm in males and 11 cm in females. Normal |

| | | | | |> 13cm form male and >11cm for female. Follow-up |

| | | | | |measure for less than normal requires cardiac |

| | | | | |exam. |

|Sacral base angle |Endplate of S1 to horizontal line angle|41( |26( |57( |Normal is 41( +/- 7(; altered in various |

| | | | | |mechanical pathologies. |

|Lumbosacral disc angle|Angle between opposing endplates of L5 |-- |10( |15( |Altered in various mechanical pathologies |

| |and S1 | | | | |

|Hadley’s S curve |Line along the inferior surface of TP |Smooth across | | |Injury / facet subluxation |

| |along lamina along articular process |joint | | | |

| |across joint | | | |AP and Oblique views may be used. |

|Ferguson’s gravity |A perpendicular line is drawn from the |within 1 cm of | | |Altered in various mechanical pathologies |

|line, Ferguson’s |center point of L3 body |sacral | | | |

|weight line, lumbar | |promontory | | | |

|gravity line | | | | | |

|McNab’s line |A line along the inferior endplate |Should be above | | |Famous but not very useful; extension malposition,|

| | |superior | | |normal variant. |

| | |articular | | |Originally used on recumbent positioning, weight |

| | |process | | |bearing has an effect. |

|Ullmann’s line |Endplate line through S1, perpendicular|L5 behind the | | |Detection of subtle spondylolisthesis when L5 body|

| |from sacral promontory |line | | |crosses perpendicular line. |

| | | | | |Decreased lordosis may give false (+). |

|Interpediculate |Shortest distance between inner | | | |Widened in intraspinal tumors, fracture / trauma; |

|distance |surfaces of opposing pedicles | | | |narrowed in spinal stenosis. |

| | | | | |Always wide on kids. |

|Eisenstein’s method |Tips of superior and inferior articular|Variable |15mm | |Spinal stenosis suspected when less than 15mm |

|(line) Unreliable. |processes joined. Distance between |12 is normal | | |Not reliable, indicates need for CT or MRI. CT |

| |posterior midbody and this line (except| | | |or MRI for (+). |

| |at L5) | | | | |

|Intertrochanteric line| | | | | |

|Klein’s line |Inclined line through neck of femur – | | | |Slipped femoral capital epiphysis when head does |

| |tangential line to outer femoral neck, | | | |not intersect line; often presents with knee pain |

| |head just overlaps laterally | | | |(not hip). |

|Teardrop distance |Femoral head – teardrop distance |9mm |6mm |11mm |Early Perthes or other inflammatory joint disease |

| | | | | |may widen the space more than 11mm or create a 2mm|

| | | | | |difference from the normal side |

|Hip joint space width |Fermoral head – acetabulum distance. | | | |Various joint diseases decrease these distances: |

| |superior | | | |Degenerative joint disease |

| |axial |4mm |3mm |6mm |Rheumatoid arthritis |

| |medial (Kohler’s to head) |4mm |3mm |7mm |Degenerative (OA) and rheumatoid arthritis |

| | |8mm |4mm |13mm | |

|Protrusio acetabuli |Pelvic inlet-outer obturator. | | | |Protrusio acetabule (Paget’s disease, etc.) when |

| |Acetabulum should be lateral to the | | | |acetabulum is medial to the line. |

| |line | | | | |

|Presacral space |Soft tissue density between the rectum |Child: 3mm |1mm |5mm |Soft tissue mass (tumor, infection, hematoma), if |

| |and anterior sacral surface. |Adult: 7mm |2mm |20mm |exceeds maximum distance. |

|Shenton’s line |Smooth curvilinear line along medial | | | |Femur dislocation or fracture if line is |

| |femoral neck and superior obturator | | | |interrupted, femoral neck fracture, slipped |

| |border | | | |femoral capital epiphysis. |

|Boehler’s angle |Three superior points joined on the |30-35( |28( |40( |Calcaneal fractures may reduce the angle to less |

| |calcaneus. Posterior angle is | | | |than 28(. |

| |measured. | | | | |

|Femoral neck angle |Lines through the axis of the femoral | |120( |130( |Coxa Vera: less than 120( |

| |shaft and neck | | | |Coxa valga: more than 130( |

|Gleno-humeral joint |Average humeral head-glenoid distance |4-5mm | | |Adding, dividing by three and comparing, |

|space |(superior, middle, inferior). | | | |degenerative and crystal arthritis diminish the |

| | | | | |space. Posterior dislocation may widen it. |

|Acromial-clavicular |Lateral tip clavical to medial aspect |Male: 3.3mm |2.5mm |4.1mm |Distance divided by 2; traumatic shoulder |

| |acromion |Female: 2.9mm |2.1mm |3.7mm |separation; degenerative arthritis decreases |

| | | | | |distance. Separation and resorption widens |

| | | | | |distance. |

|Acromio-humeral joint |Solid white line of the articular |9mm |7mm |11mm |11mm or less rotator tear. |

|space |acromion to the head of humerus | | | |Arthritic changes, dislocation/subluxation; |

| | | | | |rotator cuff tear decreases distance. Subluxation|

| | | | | |and dislocation increases distance. |

|Gailula lines (three |Draw proximal line of proximal portion | | | | |

|arcs of the wrists) |of proximal row; then the distal | | | | |

| |portion of the proximal row; and the | | | | |

| |proximal portion of the distal row. | | | | |

|Van Akkerveeken’s |Endplate lines at opposing segments. |Equal measures | |1.5mm differ|Nuclear, annular and posterior ligament damage if |

|measurement |Measure from the posterior body to | | | |more than 1.5mm difference. |

| |point of intersection. | | | | |

In slide testing for Dr. Kettner, if it’s in a box, it’s an infection.

Spondylolisthesis: Meyerding’s grading divides the sacral base into quarters with the relative position of the posterior body of L5 determining grades I - IV (25%, 50%, 75%, or 100%).

A more accurate method is measuring the distance of slip [of the slipped vertebra] and dividing by the length of the endplate of the stable (unslipped) vertebra.

Canal body ratio or Stenosis of vertebral canal: Take the ratio of the vertebral body to the canal; divide the canal by the body. Less than 82% is stenosis. More accurate than sagittal canal dimension method above but plain film is not good enough no matter what. CT or MRI is the best form of examination.

In blocked vertebrae: if congenitally fused, there is a C type cavity where the disc was, as opposed to a fused block vertebra.

Vastine-kinney angle (sella turcica)

VanAkkerveeken and flexion and extension have been largely replaced by the more sensitive compression/distraction study.

Lateral projection; draw two lines through and parallel to opposing segmental endplates until they intersect posteriorly. The distance from the posterior body margins to the point of intersection is then measured. Alternatively, the displacement can be assessed by measuring the offset in the oppoosing body corners

Should be

Lateral bending study

• may suggest ligament laxity and/or muscle spasm

• poor correlation between this and clinical picture

PRINCIPLES OF X-RAY INTERPRETATION.

Seven categories of bone disease:

Congenital, trauma, arthritis, tumor, infection, hematologic, nutritional/metabolic/endocrine (VICTANE?).

Analysis of the lesion

- Skeletal location

- Position within bone

- Site of origin

- Shape

- Size

- Margination

- Cortical integrity

- Behavior of the lesion

- Matrix

- Periosteal response

- Soft tissue changes

- Joint changes

Preliminary analysis

- Clinical data: age, sex, race, history

- Number of lesions

- Symmetry of lesions

- Systems involved

Supplementary analysis

- Other radiologic procedures

- Lab exam

- Biopsy

| |Begign |Primary |Secondary |

|Age (decades) |123 |1234567 |4567 |

|Size: | | | |

|0-6 cm |+++ |+ |+ |

|6+ cm |+ |+++ |+++ |

|Monostotic |+++ |+++ |++ |

|polyostotic |+ |+ |+++ |

|Cortical destruction |- |+++ |+++ |

|Periosteal resction | | | |

|Solid |+++ |+ |- |

|Laminated |++ |++ |- |

|Spiculated |- |+++ |+ |

|Codman’s |++ |++ |+ |

|Destruction | | | |

|Geographic |+++ |+ |- |

|Motheaten |- |+++ |+++ |

|Perireactive |- |+++ |+++ |

|Margins: | | | |

|Sharp |+++ |+ |+ |

|Inperceptiple |- |+++ |+++ |

|Matrix |+++ |++ |- |

|Soft tissue mass |- |+++ |+ |

|Joint space |- |- |- |

OSTEOLYTIC BEHAVIOR

Geographic lesion

Solitary

Greater than 1 cm

Sharp margin

Motheaten lesion

Multiple

2-5mm

ragged margins and coalescence

imperceptible transition

permeative lesion

multiple

less than 1mm

imperceptible transition

OSTEOPLASTIC BEHAVIOR

Diffuse lesion

Homogenously sclerotic (“ivory”)

Obliterated corticomedullary junction

Localized lesion

Single or multiple

Irregular, hazy border

Asymmetrical

MIXED BEHAVIOR

Both osteolytic and osteoblastic features

Table 7.1 - Normal Laboratory Values:

Acid phosphatase, alkaline phosphatase, calcium, CBC (hematocrit, hemoglobin, RBC, WBC), C-reactive protein (CRP), ESR, phosphorus, protein (total or fractions [albumin, globulin]), special antigens (HLA B27, RA factor), uric acid.

DYSPLASIA

Achondroplasia – most common form of dwarfism. “champagne glass” pelvis or “wine glass” pelvis; normal is brandy snifter. A more rectangular shaped pelvis, the scapula also appears blunted; can demonstrate coxa vara or valga; interpedunculate space narrowed and central canal stenosis with a scalloped appearance on lateral X-ray via dural actasia (due to a lack of room for the cord allowing for the pulsation of the CSF to impress on the vertebra) gives a bullet shaped vertebra. most common complication is central canal stenosis and DJD in the adult (multiple laminectomy often necessary); frequent cause of neonatal death stenosis of foramen magnum. This is a bilateral process with grossly short bones; proximal more than distal affected and longer bones more than shorter bones yields the rhizomelia classification. Higher, flatter forehead; depressed nasal ridge; protruding buttocks and abdomen; incomplete extension of arm (shallow olecranon fossa); champagne glass pelvis, short extremities (rhizomelia), diminished interpeduncular spaces AP view; affects endochondral bone development (achondroplasia) but normal intramembranous development; spine typically acquires normal length; and trident hand is a classic X-ray finding (when patient completely opens hand, the thumb is off by itself, first two fingers and second two fingers group).

Overall etiology unknown; 80% considered spontaneous. There are lethal forms, serious complications in adult; normal intelligence.

Cleidocranio dysostosis (dysplasia) – common appearance of MID-LINE defects. Appearance of lots of wormian bones in occipital region with a lack of lambdoidal suture. They do not qualify as a dwarf though short and with a little larger head and smaller face than usual (altered craniofacial) and depressed shoulder. Cleft palette, cleft lip, missing pubic symphasis, prevalent wormian bone, small face in relation to skull, drooping shoulders and slender neck, high mobility of shoulders allowing for a large amount of self love arm wrapping. This is not rare, though not common. Smaller ribs at the top giving a funnel shaped chest cavity. 10% have congenital absence of the clavicle.

Marfan’s syndrome – arachnodactyly; long, slender foot and hand bones. Occular abnormality (lens dislocation) and very tall (over 6 foot). There is a tendency for dissecting aortic aneurysms. Look for the thumb sign: fold your thumb into your hand and close your fingers around it and push the thumb under; typically you can see the entire distal phalanx sticking out the other side. Ligamentous laxity. Equal prevalence is equal between men and women. Body habitus is on the thin side with low body fat and joint laxity. About 45% have scoliosis. Poor dentition with lots of dental caries. Consider, upon seeing a scoliotic child, how tall are they, are they wearing glasses, how are your teeth, can you bend your thumb, do you have a murmur. Often these people have valvular and chamber deformities in the heart. Enchondral bone growth exagerated, though intramembranous is pretty normal. Pectus excavatum results in heart disposition. Common and clinically recognizable. First site of aortic aneurysm is the arch (first highest pressure zone in the aorta) second is in the bifurcation of the common iliacs (the second highest pressure zone in the aorta).

Osteogenesis imperfecta (OI) – hands demonstrate arachnodactyly, short stature due to multiple fractures causing premature closure of growth plate. Bone has a thin cortex and lack of density in trabecula. Fractures can lead to subperiosteal bleeding leading to a large, exuberant callous formation. Bilaterally curved femurs, the degree of bowing can indicate the severity of affliction. Trivial trauma can produce fracture. Osteoporosis with great fragility, 90% have a blue sclera due, and abnormal dentition. There are two forms:

Congenitive: worse, recognized at birth, higher mortality rate, if they live past infancy they are profoundly affected as adults.

Tartiform: comes out incidentally later.

A form of brittle bone disease along with osteopetrosis.

SCLEROTIC DYSPLASIAS

Maloryostosis – part of the bigger group of sclerosing ostoses. Adds cortical bone endogenously and exogenously. This has more cortical bone than is normal and increased density inside the bone without changing the contour of the bone. Most findings are incidental (found during investigation of a different complaint). Symptomology produces through compression of soft tissue, nervous tissue, tendinous tissue, etc. offering a molten waxed appearance. Most common in the extremities.

Osteopetrosis – “bone-within-a-bone” polyostotic, increased densities a.k.a. chalk bone; very unusual. Bone has no exaggerated osteoblastic activity. Trivial trauma can produce fracture. A form of brittle bone disease along with OI.

Osteopoikelosis – polka-dot appearance of bone on plain film, normal bone scan, no pain syndromes, does not appear to change the bone strength.

KNOW A BUNCH OF THE FOLLOWING STUFF:

Asphyxiating dysplasia

Aperts with brachycephaly (short skull) not bradycephaly,

Schaphocephalic (boat head) normal coronal suture growth and early closure of sagittal suture.

Turycehpaly

Underdeveloped distal palanges, bulbos nose and thick, coarse hair = trichorhinopalangeal

Shortened metacarpals.

Stippled epiphysis – multiple growth centers

Spondyloepiphyseal dysplasia – heaped up appearance of the body of the vertebra.

Angleman’s disease (progressive diaphysiseal dysplasia)– demonstrates less density than maloryostosis (no candlewax appearance) and is internal only.

Picnodysostosis – very small, pinched faces (elfin), more head than face and increased density within the bone. Osteolysis (resorption of bone).

Acroosteolysis – know the film. With skin induration and retraction of soft tissue and difficulty in swallowing is not picnodysostosis but is scleroderma.

Most typically, an acquired blocked vertebra will produce greater degrees of DJD.

Developmental cleft – a normal “step” in a vertebral body

Limbus vertebra – when the nucleus pulposis goes through the ring apophysis (growth ring) of the vertebra instead of into the endplate or through the longitudinal ligament. It is not mobile because the sides are still in fusion with the remainder of the ring and body.

Block vertebra is an indication for flexion/extension series to examine ADI instability. The classic block will demonstrate a “wasp” waist at the rudimentary disc area.

CONGENITAL

Hyperostosis internus (the whole inner table is bigger/thicker); frontalis is limited to the frontal bone.

Parietal foramen – congenital failure of the fontanels to ossify.

Hypoplasia of the frontal sinus; clinical significance – none. There are two spikes to sinus formation: just before puberty and just before skeletal maturity. Concern for a benign frontal osteoma.

Occipitalization (craniovertebro synostosis)– occiput and C1 fusion; see what appears as a foramen like radiolucency in that area. Express concern for transverse ligament damage; pay attention to the ADI (accumulated microtrauma will increase the ADI resulting in weakening transverse ligament possibly resulting in guillotine). This condition calls for flexion/extension cervical series.

Spodylo-schisis – modified submental - failure (agenesis) of both anterior and posterior tubercle C1.

Paradental sulcus

Frontal suture closure result in taller head; mid sagittal closure results in craniocephaly.

Ponticulus posticus (arcuate foramen) – a physiologic pattern of soft tissue calcification:

Serum Ca++ Tissue

1. Physiologic normal normal

2. Metastatic metastatic normal

3. Dystrophic normal abnormal

About 10% of patients will have recognizable complaints associated with this. This is particularly important with concern to VBAI.

Os odontoidium – failure in ossification of dens to body C2.

Cervical digit – an articulation on/of a rib.

Cervical ribs

Sacral agenesis

Posterior scalloping – from achondroplasia with dural ectasia; or from NF

Geriatric:

Things you expect to see: OP, compression, DJD, change in contour

Surprises that are common to see: congenital anomalies, benign tumors (fibrous), Paget’s disease

License stealers: Metastasis, AAA, infection (lung or bone)

Old men: less OP

Young adult:

Things you expect to see: trauma, posture abnormalities.

Surprises that are common to see: Fibrous lesions, congenital anomalies

License stealers: infection

Pediatrics:

Things you expect to see: no abnormalities.

Surprises that are common to see: Fibrous lesions, congenital anomalies

License stealers: Metastasis, infection

Ununited apophysis.

Cervical digit.

Sprengel’s – unilateral elevation of scapula; actually, failure of scapula to descend.

Omovertebral bone – often seen with sprengel’s. Often associates Klippel-Feil syndrome, blocked vertebra, webbed neck

Rhomboid fossa – a muscular impression on X-ray. No clinical consequence.

Hemivertebra – only neatly triangular when drawn.

Scrambled spine, also a structural scoliosis.

Butterfly vertebra – missing primary ossification centers in the body, apparently migrating to the levels above and below.

Intrathoracic rib – unlikely to produce any complications.

Synostosis of rib (bifid rib, or costal synostosis). Failure to separate.

Elongation of L5 TP, considered a physiologic variant most likely calcification of iliolumbar ligament.

Spina bifida in the lumbar vertebra seems to associate with increased disc pathology.

Reversed thoracic kyphosis or thoracic lordosis: recommendable to perform thoracic cage mensuration. If linked with a heart murmur, then straight back syndrome. If there is a heart murmur it is likely a result of floppy valve syndrome. High percentage have pathology requiring valve replacement.

Costochondral ossification – physiologic calcification – everything (serum and tissue calcium) is normal.

Thoracolumbar transitional ribs.

Notochordal persistency resulting in cupid’s bow.

Winking owl sign – metastasis (most common) or congenital. Sclerosis of the contralateral indicates congenital because it takes a long time to sclerose.

There is an apparent correlation between spina bifida and DJD.

Springboard divers, interior lineman, gymnasts are at high risk for acquired splondylolysis.

If flexion/extension demonstrate 3% or more translation you confirm unstable listhesis; less than 3% does not rule in or out anything.

Oppenheimer’s ossicles – nonunion of growth centers.

Lordodic sacrum

Injection granulomas [from arthritic injections in the gluteus] called dystrophic calcification (regularly seen in patients).

Pseudotumor of the pelvis – results from observation of the growth plate between the ischial and pubic rami.

Fabella – sesamoid-like bone in lateral gastroc often confused with synovial chondroplasia.

Rockerbottom foot – missing tarsal bones

Bipartate sesamoid bones.

Tarsal coalition – bony bars in the tarsals.

Pseudotumor of the humerous – lucency that results from the attachment of rotators – it disappears on baby-arm X-ray

Supracondylar process – found on the humerous and points toward the elbow joint (normal variant). Often confused with osteochondroma – points away from the joint, found anywhere on the body, and has a condral cap.

Maudline’s deformity – ulnar deviation of wrist

Ulna minus – short ulna.

Ununited growth center of ulnar styloid process.

Radius minus.

Synostosis – failure of the bones to separate.

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