THORACIC – not a big player in your practice compared to ...



THORACIC – not a big player in your practice compared to lumbar or cervical.

Trauma – mid and L/T region are the most common areas in T/S for fracture. Young people with no OP will have the greatest compression in the low T/S. If older, look to the kyphotic (6,7,8) area. Higher areas – get a little nervous (malignancy). A new and old fracture are not easily distinguished on X-ray. Palpate or percuss for “ouch” sign to differentiate new from old. Osteopenia, mets, and multiple myeloma are most common reasons for fracture in T7 area. T4 through T9 are the critical area of the spine because or the poor blood supply. Small disc bulges can compress the anterior spinal artery leading to ischemia of the anterior half of the spinal cord and can lead to synrinx. A 2mm intrusion into the canal can compromise the blood supply. Outside of bulge and fracture, DISH can intrude.

Tumors – this is a great place because of blood supply. Most common benign spinal tumor is hemangioma. Multiple myeloma – you will see that in your practice at least once in your career. MR is the most practical test for ALL tumors benign or malignant. Look to the flat bone most often (rich blood supply) for tumor presence.

Arthritis – OA is most common especially in the mid and lower regions. T10 is most common region for OA of the costovertebrals. RA is not very likely in the T/S. AS is possible – starts at the SIJ and then goes to T12 and moves up and down from there. DISH – these people tend to calcify their tissues for no particular reason. DISH will either remove or inflame the sympathetic chain – will affect all the organs, hence prevalence of diabetes.

Specials – scoliosis will show here more predominantly here – you will see more of this than any of the other things mentioned so far. Most common cause of scoliosis is antalgia. Common causes of scoliosis: hemivertebra, unlevel pelvis. Don’t use the term “primary curve” – it is either the biggest or the first. Use instead “major curve” for the larger and “minor” for any others. X-ray views: AP, LAT, and lay them on the table and forcefully bend them straight for a view. If you can’t straighten them out, you can’t adjust it away. Next take the left hand shot to determine bone maturity. Idiopathic scoliosis: look to the righting reflexes (eyes, ears, and mechanoreceptors). We all have a natural figure 8 sway to keep in balance – a large figure 8 is risk for scoliosis. High risk are tall females with a family member with scoliosis. Look also at their academic standing – idiopathic scoliosis patients are usually in the bottom ¼ of the class until the hit college where they become the top ¼ of the class. Most important X-ray is the lateral to look at the discs in the lower T/S – they should be flat, in scoliosis they are wide in front leading to a flat spine. (1) Decreased AP curves lead to instability and (2) decreased bilateral biomechanics balancing and eventual (3) decreased lateral proprioception. One theory is that as the body goes through a growth spurt, the brain is not ready to handle the increased proprioception, but can still handle the visual and auditory mechanisms. 1/3 to ½ of idiopathic scoliosis have pathology in the cord (Arnold Chiari, syrinx, etc).

ARTICLES: Childhood scoliosis clinical indications for MRI. There is a good chance that “idiopathic” scoliosis is not – most likely there is indication for MR to investigate cord problems.

Treatment:

1. Adjust (especially upper cervical and sacrum)

2. Russian stim three times per week at mid-axillary line on convex side of curve.

3. ROM using Leander table with interest to the apex of the curve

Cost comes out to about 30,000 spread over 4 years (from age 12 to 16 – spinal maturity) compared to BC/BS medical intervention of about 100,000. The real downside to scoliosis is cosmetic more than anything else – you get shorter. Eventually, you may have pain resulting from OA over the years on the concave side. Pain on the convex side is usually muscular. Very rarely do you end up with compromise to the heart – this resulting from the heart coming in contact with something that it should not resulting in a change of conduction pattern. Surgical treatment for adult painful scoliosis indicates that none of them got better, two died, and a few had complications from surgery (in a study on 40 people). Painful scoliosis in children – look for nidus (pain at night relieved by aspirin) of osteoid osteoma.

Scheuermann’s disease – endplate collapse, predominantly in adolescent males, of at least three vertebra in a row. Presumed to result from intrusion of the disc into the endplate, like multiple Schmorl’s nodes resulting in disc degeneration. If they are young, treatment includes Boston brace to prevent further degeneration, perhaps even reversing the progression. In the middle-aged, there’s nothing to do but treat for degenerative disc disease. The bodies of the vertebra will elongate A to P.

Thoracic disc herniation – dull, deep retrosternal or retrogastric pain with a band like anterior chest pain. Broken up to three ranges: T1/T2 into arms, T3-T6 very rare if ever, T7-T12 more common. This is a very difficult diagnosis. One thing for high risk is interdiscal calcification may lead to protrusion into the spinal canal. Most asymptomatic, 37% of people with no pain had T/S herniation.

Remember in the young you will see ring apophyses.

Hahns.

Butterfly vertebra not significant unless asymmetrical

Hiatal herniation is very common in kyphoscoliosis

Narrow chest syndrome

LUMBAR – diagnosis of LBP. Hardly anybody gets it right.

In every patient complaining of LBP, three initial questions must be answered:

1. Where is the pain?

2. Is the back pain acute or chronic?

3. Is the pain mechanical or non-mechanical?

|LOW BACK PAIN |

|Lumbosacral |Other locations |

| |

|Chronic |Acute |Consider other causes |

|Degenerative arthritis? | | |

|Spondylitis? | | |

|Postural? | | |

| | |Above L1 |Chest, gallbladder, pancreas, aorta, T/S |

| |Non-mechanical |Mechanical |Flank |Kidney, ureter, retroperitoneum, chest, GB |

| |Referred pain? | | | |

| | | |Groin |Hip, ureter, testicle, inguinal area, vascular, GI |

| | | |Buttock |pelvic, vascular, SI |

| | | |Thigh |Hip, vascular, pelvic |

| |Simple mechanical |Radicular |“OMINOUS” |

|History |Mechanical precipitant |Radicular pain distribution |Known cancer |

| |Worse with back motion |Worsens with Valsalva maneuvers |Steroid/anticoagulant therapy |

| |Relief with rest |Neurologic symptoms |Elderly age |

| |Back pain predominates |Leg pain predominates |Unrelenting, progressive pain |

| | | |Fever/drug abuse/bacteremia |

| | | |Systemic symptoms |

| | | |History of trauma |

|Examination |Limited back ROM |Positive traction signs |Excruciating pain, no better with rest |

| |Paraspinal muscle spasm? |Neurologic findings? |Fever |

| |No traction/neurologic signs | |Weight loss |

| | | |Bilateral, atypical, or worrisome neurologic findings |

|Common causes |Lumbar “strain” |Herniated disc |O - Osteomyelitis |

| |Early disc disease |Spondylosis |M - Metabolic bone disease |

| |Degenerative arthritis |spondylolisthesis |I - Inflammatory spondylitis |

| |Facet syndrome | |N - Neoplasms |

| | | |O - Others (hemorrhage, abscess) |

| | | |U - Unstable spine (fractures) |

| | | |S - Spinal cord/canal disease |

Ranking tables computed as characteristic of the four general diagnostic categories

|Category |Positive criteria |Negative criteria |

|Simple LBP |Night pain: no |Regional sensory loss: yes |

| |Lumbar flexion > 5cm |Superficial tenderness: yes |

| |SLR limited by hamstrings |Typical LMN pattern |

| |History of spinal fracture: yes |Involvement of one or two nerve roots |

| |Structural scoliosis: yes |LP = BP |

| |Thigh pain on pain drawing |Site of pain: ankle |

| |Walking makes back pain (BP) worse: no |Age > = 55 |

| |Coughing makes BP worse: no |Age < = 20 |

| |Coughing makes leg pain (LP) worse: no |SLR 46-74( |

| |Walking makes LP worse: no |Night pain: yes |

| |Age 20-55 |Weight loss: yes |

| |Caused by pregnancy |Dermatomal parasthesia: yes |

| |Intolerance of treatments: yes |Systemic symptoms: yes |

| |Dermatomal parasthesia: no |No back pain |

| |Duration: recurring |Overreaction to examination: yes |

|Root pain |Typical LMN pattern |Nonanatomical pain drawing |

| |Involvement of one or two nerve roots |SLR not limited |

| |Sensory loss: yes |Structural scoliosis: yes |

| |Positive myelogram |No leg pain |

| |Loss of reflexes: yes |Not mechanical or non-mechanical BP |

| |Root pain on pain drawing |Non-mechanical BP |

| |Motor loss: yes |Site of pain: thoracic |

| |SLR limited by LP |Lumbar flexion > 5 cm |

| |SLR < = 45( |No myelogram |

| |Sciatic list: yes |BP > LP |

| |LP > BP |Thigh pain on pain drawing |

| |Site of pain: calf |Walking makes LP worse: no |

| |Coughing makes LP worse: yes |Very bizarre pain drawing |

| |Walking makes LP worse: yes |Systemic symptoms: yes |

| |Site of pain: ankle |Kyphosis; yes |

|Spinal pathology |X-rays: true pathology |X-rays: mechanical problem |

| |Non-mechanical BP |Pain simulation with rotation: yes |

| |ESR > 25 mm |SLR < = 45( |

| |Acute duration < = 6/12 |Whole leg numbness: yes |

| |Age > = 55 |Walking makes LP worse: yes |

| |Kyphosis: yes |Sciatic list: yes |

| |Systemic symptoms: yes |Pain at tip of tail bone: yes |

| |Other systemic diseases: yes |Whole leg giving way: yes |

| |Weight loss: yes |Mechanical BP |

| |History of carcinoma: yes |Duration: recurring |

| |Age < = 20 |Cause: bend-lift |

| |Onset: gradual |Never pain free last year: yes |

| |Site of pain: thoracic |Site of pain: calf |

| |Typical UMN pattern |SLR limited by LP |

| |Whole leg giving way: no |X-rays: normal |

|Anormal illness behavior |Whole leg giving way: yes |Acute duration < = 6/12 |

| |Increase SLR on distraction: yes |Source: GP referral |

| |Pain simulation axial load: yes |Pain simulation axial load: no |

| |Nonanat tenderness: yes |Whole leg giving way: no |

| |Overreaction to examination: yes |Overreaction to examination: no |

| |Whole leg numbness: yes |Motor loss: yes |

| |Walking makes BP worse: yes |SLR > 45( |

| |Pain simulation rotation: yes |Positive myelogram |

| |Intolerance of treatments: yes |Myotomal weakness: yes |

| |Nonanatomical pain drawing |Dermatomal parasthesia: yes |

| |Source: problem referral |Dermatomal numbness: yes |

| |Very bizarre pain drawing |No back pain |

| |Whole leg pain: yes |LP > BP |

| |Never pain free last year: yes |Walking makes BP worse: no |

| |Litigation involved: yes |Age > = 55 |

Etiological factors for back pain:

|Intrinsic |Extrinsic |

|Smoker |Vibration |

|Poor cardiovascular fitness |Static muscle overload repetitive strain |

|Poor trunk muscle endurance |Acute overload |

|Depression |Prolonged sitting |

|Job dissatisfaction | |

Triad for chronic pain management

I. Education

II. Functional restoration

III. Psychosocial factors

Pathophysiology of deconditioning syndrome

Sciatica

|Cause |When to suspect |Diagnosis |

|Nerve root disease |

|Herniated disc |L5 and/or s1 |Presumptive and/or CT scan and/or myelography |

| |Traction signs | |

| |Typical history | |

|Degenerative spondylosis (and/or) spinal |X-ray changes |X-ray and/or CT scan and/or myelography |

|stenosis) |May be bilateral, multiple roots | |

| |Neurogenic claudication | |

| |Typical history | |

|Spondylolisthesis |X-ray | |

|Facet syndrome |Disc syndrome with “negative” myelogram |CT scan, surgical exploration |

|Pedicle kinking | | |

|Extraforaminal disc | | |

|Paget’s disease |X-rays | |

|Compression fracture |History |X-rays, bone scan |

|Vertebral neoplasm | |Find the cause |

|Herpes zoster |Dermatomal rash |Visual |

|Arachnoiditis |Prior surgery and/or myelography | |

|Primary spinal neoplasm |Insidious, progressive, nocturnal pain |Myelography, CT scan, and/or exploration |

| |Often multiple root and/or cauda equina syndrome | |

|Epidural/subdural metastases or abscess |History |Myelography/CT scan, and/or exploration |

|Osteomyelitis |History, ESR |Bone scan. X-ray |

|Lumbosacral plexus disease |

|Multiple nerve root involvement unilaterally |Cancer |Abdominal/pelvic CT scan, and/or |

| |Anticoagulation |Ultrasound |

| |Aortoiliac aneurysm |EMG/nerve conduction studies? |

| |Pelvic disease | |

| |Diabetic amyotrophy | |

|Peripheral nerve disease |

|Pyriform syndrome |Female with dyspareunia |Clinical findings, EMG/nerve conduction study |

| |Pain worse with extension/abduction of hip | |

|Meralgia paresthestica |History |Clinical |

|Peroneal nerve entrapment |+ Tinel sign at fibular head |Clinical, EMG/nerve conduction study |

Lumbar root syndromes

|Root |Dermatome |Muscle weakness |Reflexes affected |Paresthesias |

|L1 |Back, over trochanter, groin |None |None |Groin, after holding posture, |

| | | | |which causes pain |

|L2 |Back, front of thigh to knee |Psoas, hip adductors |None |Occasionally front of thigh |

|L3 |Back, upper buttock, front of thigh and|Psoas, quadriceps – thigh wasting |Knee jerk sluggish, PKB positive, |Inner knee, anterior lower leg |

| |knee, medial lower leg | |pain on full SLR | |

|L4 |Inner buttock, outer thigh, inside of |Tibialis anterior, extensor |SLR limited, neck-flexion pain |Medial aspect of calf and ankle |

| |leg, dorsum of foot, big toe |hallucis |weak or a bent knee jerk; side | |

| | | |flexion limited | |

|L5 |Buttock, back and side of thigh, |Extensor hallucis, peroneal, |SLR limited to one side, |Lateral aspect of leg, medial |

| |late3ral aspect of leg, dorsum of foot,|gluteus medius, ankle dorsiflexor, |neck-flexion pain, ankle jerk |three toes |

| |inner half of sole and first, second, |hamstrings – calf wasting |decreased, crossed-leg raising – | |

| |and third toes | |pain | |

|S1 |Buttock, back of thigh, and lower leg |Calf and hamstrings, wasting of |SLR limited |Lateral two toes, lateral foot, |

| | |gluteals, peroneals, plantar | |lateral leg to knee, plantar |

| | |flexors | |aspect of foot |

|S2 |Same as S1 |Same as S1 except peroneals |Same as S1 |Lateral leg, knee, heel |

|S3 |Groin, inner thigh to knee |None |None |None |

|S4 |Perineum, genitals, lower sacrum |Bladder, rectum |None |Saddle area, genitals, anus, |

| | | | |impotence |

CHRONIC LBP

Specific diagnosis

Spinal stenosis DECOMPRESSION

Stable spine Local measures

Neoplasia

Unstable spine SURGICALSTABILIZATION

Potential cord compression

OA NSAID, corset

Spondyloarthropathy NSAID

Life-long exercise program to prevent flexion contracture

Metabolic bone disease Vertebral body collapse Treat underlying disease

Reduce activity

Orthotics

Chronic pain syndrome Multidisciplinary approach tailored to the patient

Stable

Spondylolisthesis Orthotics, weight loss

(age > 25 years) Activity precautions Progressive neurologic deficit

Sciatica

DECOMPRESSION

Chronic LBP with normal lumbosacral spine X-rays

|Progressive |Weight loss? |Morning stiffness?|Non-mechanical? |Neurologic |Intractable disc |Postural? |Psychogenic? |

|worsening for | | | |symptoms or |disease? | | |

|weeks/months? | | | |signs? | | | |

| | | | | | | | |

|OMINOUS |Neoplasm? |Polyarthritis? |Referred pain? |Disc? |Consider: |Obese |Litigation? |

| |Subacute |Sacroiliitis? | |Cauda equina? |CT scan, or |Paunchy |Disability? |

| |osteomyelitis? |Polymyalgia | |Spinal tumor? |myelogram, or MRI|Postpartum |Depression? |

| |Metabolic bone |Rheumatica? |Endometriosis? | | |Lordosis |Psychosis? |

| |disease | |Uterine myomas? | | |Pelvic tilt |Malingering? |

| | | |Prostatitis? | | |Unequal leg lengths | |

| | | |GI cancer? | | |Muscle weakness | |

| | | |Retroperitoneal | | | | |

| | | |process? | | | | |

| | | | | | | | |

|Bone scan |Bone scan |ESR |Pelvic rectal |Consider: | | | |

|ESR |ESR |Sacroiliac films |exam, etc |CT scan, or | | | |

| | | | |Myelogram, | | | |

| | | | |Or MRI | | | |

Possible qeustionsfor the final:

Name three ortho tests for LBP and describe how to do it

SLR/Braggards Disc bulge 85%

WLR disc bulge 92%

Valsalva (Dejerines) disc

Kemps Facet(disc

Shane started here.

Lumbar Spine:

Facet:

Spondylosithisis: Graded 1-5, happens when you are young, most common age is about 4yo to 20. Older patients is trauma. Dance, diving, are some of the sports that predispose. most common im men, during 1st and 2nd growth spirts. most common injury is a hyper-extention injury. Adult has strong enough pars to handle stress. Myerdings method of measurement is best. With a child use mm measurement to track progression. In past thought it was congenital because it is often found with a spina bifida at that level, but the spondilolysthisis is not congential. Most patients will not be able to account for injury, because it happened so long ago. Do not need obliques to see, look for ant slipage. Other common findings with spondylolysthisis is DJD. Facet arthrosis is common cause of pain complaint. Adj and they will respond well to care. Perform stress views with hanging and compression 3-5 mm movement is unstable. These unstable patients are surgical candidate. There is a good success rate of decrease in pain. Perform stress views when patient does not respond to care. 98% of time at L5. If you have 20% or greater the odds are that it was spondylolysis. It is generally not a good idea to wiggle the SP of an SPLLT – it will hurt the patient enough such that they will not like you. The spondylo move (Diversified) does not push the body back, there is stuff back there that will prohibit such a result, but you will open up the facets. Most will respond to treatment.

Compression fractures: acute and you suspect compression and compromise, run neurological tests and consider sending out for CT.

OA: narrowing, subchondral sclerosis, osteophytes – no big deal

Facet arthrosis: can lead to lateral canal stenosis

Schmorl’s node: clinical relevance – may interrupt the nutrition of the disc. Consider this also with limbus deformity.

Baastrups: kissing spinouses that will develop a bursa that can lead to bursitis.

DISH

AS

MR findings in asymptomatic people:

Disc bulges 81

Mild or moderate dis degeneration 72

Anular tears 56

Severe disc degeneration 55

SIJ

Osteophytes come out at you on X-ray. This makes it difficult to visualize.

OCI: abnormal strain on the SIJ. Can have pain referral to the groin. This is a degenerative process. Men can get this too.

AS

SI signs that look like AS, ask about UC or Crohn’s or other enteritises.

Reisser’s sign: don’t mistake this for a fracture

Phleboliths: don’t get excited about this unless above the ischial spine

Avulsion fractures: very common. Ice treatment. Loss of function after one year is non-measurable.

most common fracture of the pelvis that you will see especially in middle aged women – fatigue fractures in the inferior ischeal ramus

shearing of a symphasis pubis that underwent prior stress/trauma can lead to fusion of that joint.

HIP – you will see a lot of people with hip pain because it refers to the back.

Trauma – elderly female, one of the most expensive. Other than that, trauma here is pretty rare. Acetabular fractures won’t walk into your office. An elderly female with back pain/hip pain may have a stress fracture coming.

Arthritide – OA in the hip is probably in the top five sites for OA. Note the hip joint space (4-5mm) and look for geodes. Osteophytes occur on the neck of the femur. 50% are idiopathic. Knee pain will refer to the hip and vice-versa. RA – lack of bone density, loss of joint space, can result in protrusio, but they have to be on steriods for this. if you see it here, they already have RA, this is one of the last places to show RA. AS – if you have such a patient, get a baseline X-ray of this.

Tumor – noy very likely. If you see an avulsion fracture in an adult, consider a bone neoplasm. If you see the lesser trochanter avulse, you have a neoplasm. Most common place for Paget’s in the hip is the coxa.

Special – osteonecrosis (ON) in adults is fairly common age 20-40 male and is often bilateral – 85% (unilateral usually associates with trauma). Black male with hip pain osteonecrosis, consider sickle cell. Gout can also cause ON, as can alcoholism, and lipid storage disease.

Age. Younger – 0-1: congenital displacement especially in girls (Ortelani’s – Tx used to be triple diaper for about three months). 2-10: transient synovitis, very common in males and gone in 10-14 days. LCP is very similar looking with first stage capsular swelling tough LCP has capsular thickening. 12-16: SCFE (slipped capital epiphysis) occurs when there is an influx of hormones (adjusting here results in chondrolysis). Osteoid osteoma or Ewings.

Otto’s hip – bilateral protrusio actabuli

Football-type hip pads cut the average number of hip fractures by 50%.

SINGH grading with Ward’s triangle

Hip pain hurts when you walk, LBP does not.

KNEE

Trauma – bone fractures, we see them but they don’t have any names. There are not very many fractures of bone outside of plateau fractures in the elderly. most common are soft tissue injuries. Six ligaments of the knee: ACL, PCL, MCL, LCL, and the menisci. They are not really a ligament though they are, they are not a disc though they histologically appear as such. No blood supply or nerve supply hence lack of pain in the meniscus. ACL: Lachman’s, Drawer’s test. A warning about acute swelling presentation is the guarding prevents positive findings. PCL: sag test – presentation of a sag when set up of an ACL test. PCL is thicker/stronger than ACL, hence PCL tear is more devastating. MCL/LCL: varus/valgus test, making sure the knee is unlocked. Joint line pain is most evident clue for meniscus tear. McMurrays test is probably best test. Most of the time the tears are in the posterior of the meniscus and that is where you will hear or feel the click or clunk. If McMurrays is negative, Apleys will also be negative. If McMurrays is positive, the next test is MRI. The neoprene knee supports are helpful in knee injuries because of the increased proprioceptive input that helps with the faulty sensory input from the ACL (a major proprioceptive “organ”).

Arthritis – in the knee is number one. It is the biggest joint with the highest stress patterns and is unstable in that there are no surrounding muscles (tendons yes, muscles no). it is at the end of two long bones making even more susceptible to damage. Best X-ray with AP is while standing, both on one film. lateral, knee bent 35( to allow view of patellar joint. OA of the patella is the most common and most difficult to see. It is the highest stressed and thickest in cartilage in the body. High risk for OA in the knee is obesity. Tx: go on a diet and adjust. RA is not a big complaint in the knee, looks the same as anyplace else.

Tumors – kids, osteosarcoma. Most likely when the osteoblasts are under the greatest stress and rate of growth.

Special – Osgood-Schlatter’s. osteochondritis dessicants (teens and elders) – thought a result of a bone bruise or repetitive changes in the joint surface.

Malignant (anterior of vertebra) include lymphoma, hodgkin, myeloma, ewing, osteosarcoma, chondrosarcoma, mets

Benign (posterior vertebra) include osteoblastoma, osteoid osteoma, aneurysmal bone cyst, osteochondroma, chrondromyxoid

You should never have cortical interruption

85 percent of all cancer deaths are a result of smoking.

Sun

Alcohol

Estrogen treatment to control menopausal symptoms is associated with an increased risk of endometrial cancer. Thus, the use of estrogen needs to be carefully discussed by patient and physician.

Radiation – excessive exposure can increase cancer risk, however, most medical X-ray machines are adjusted to deliver the lowest dose of radiation possible.

Nutrition – obesity increases the risk of colorectal, breast, and uterine cancer. High fiber foods may help reduce the risk of colorectal cancer and can be wholesome substitutes for high-fat foods.

Lung, liver, brain are most common areas where mets results in death

McGee page 382

Infections

Hip

L/S

Fracture

Tumor

Osteonecrosis

Pelvis

Arthritis (including AS)

Knee

BOARDS: People tend to waste more time on over-thinking when looking at X-ray, otherwise this is really pretty easy. They tend to like license stealers. Test designed to catch the lowest 10%.

Most likely on a skull is ADI as far as whether or not to adjust. Don’t worry about the shape of the skull. Look for areas of black or white. Black – circumscripta (Paget’s). Black hole – many holes different size (mets), many holes same size (multiple myeloma). Thalasemia and sickle cell in skull are generally not on Part IV. Increased hat size Pagets. 7’2” person think of sella turcica. There is a good chance you won’t even see a skull. Most likely you will see “it” on the lateral

MRI of skull – don’t worry about it, no-one will get it. Look at the answers, relate to the question and process elimination.

CERVICAL

LAT - ADI number one (trauma or RA). Hangman’s, clay shovelers, fractures. Soft tissues swelling - in a kid think infection in an adult think tumor. After that look for other stuff. 95% of pathologies (and answers) found here. Consider congenital block and hangman’s fracture. Avulsion or teardrop fractures. DISH (swallowing).

APOM – look at this last, two things – Jefferson’s fracture lateral masses too wide over C2 and odontoid. Most odontoid fractures on the test are wrong answers – too many things for mock lines.

APLC – look to the apex pancoast then go to trachea for any deviation. Note for calcification in the carotid artery. Uncinates best visualized here. Cervical ribs.

OBL – for IVF patency. Should all be same size. One larger than above or below think neuroblastoma or artery. Also good spot to note for cervical ribs.

MRI – hopefully you have a history too indicating disc bulge. Look at the cord MR will also show everything – they are more interested that you can recognize anatomy.

Flexion/extension – look for ADI stability. You are not allowed to measure or touch any film, so you’ll have to be good at eyeing it.

THORACIC – not much here.

LAT – look here first more pathology on lateral. First compression fracture – look at the kyphosis. In young (teens) Scheuermans. In younger lymphoma – one or more white vertebra (Paget’s, blastic mets, Hodgkins). DISH (with this the discs are normal size), AS (square bodies shiny corners), multiple myeloma (looks just like compression fractures), silver dollar sign (eosinophilia granuloma or hodgkins), winking owl sign, hemangioma (look at the borders of the body – sharp cortices are hemangioma, fuzzy is Paget’s)

AP – young scoliosis. Adult pancoast (TOS, Horner’s, neck/shoulder history).

CHEST – there will be at least one question, very obvious.

AP – heart size first (big not small most common cause is CHF). Gutters should be sharp. Then go up around and down looking for any areas of white. Typically you will see baseball size whiteness primary bronchogenic carcinoma. Small on side is solitary pulmonary nodule malignant. multiple white ones are mets. Multiple are miliary TB (bird seed) and histoplasmosis (bigger than bird seed). Geometric shape other than round is pneumonia. You must keep taking X-ray until all pneumonia is gone otherwise you might miss a cancer. Black areas – pneumothorax. Spend most time on AP, if you can’t find it, go to LAT.

LAT – pneumonia in lower area, then look at spine. Laterals are good for MVA to see sternal fracture from hitting steering wheel.

LUMBAR

LAT – everything shows up here except. First SPLLT. Then degenerative change on L4. Next is aneurysm – should look like a tube with no expansion. Most common benign tumor of the spine is hemangioma, mets, blastic, lytic bodies. Finally DISH, AS, knife clasp (large SP with spina bifida below).

AP – gallstones and kidney stones. SIJ in kid for AS. Count pedicles (10) if 9 note congenital or mets. Transitional segments. There is always an aneurysm on the boards.

OBL – scotty dog find pars fracture.

PELVIS

AP – think of age. Young – hips – LCP, SCE. Adult look for AS. Older is Paget’s. most common place for mets is flat parts of pelvis, for Paget’s is at roof acetabulum area. Soft tissue 40 woman with popcorn ball in pelvis is …. Slipped epiphysis (look bilaterally) do not manipulate you will be sued. LCP in kids

MRI – disc bulge.

EXTREMITIES

SHOULDER – high risk look to lung field for white mass. Calcification in cuff. Some mets in head of humerus is rare finding. OA is uncommon. Clavicle fracture is real common.

KNEE – kid osteosarcoma. Adult ligament damage. Osteochondritis dessicans. Elderly OA

ANKLE – soft tissue [swelling].

FOOT – stress fractures, gout

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Recurrent pain

Illness behavior

Muscle hypertonicity

Pain avoidance behavior

Depression

Immobilization and disuse

Loss of cardiovascular fitness

Joint stiffness

Muscle weakness

Incoordination

Atrophy

( static and dynamic muscular performance

Tumors and tumor-like lesions

metastatic

secondary

Primary

malignant

Benign

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