Boards part 4_review

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Boards part 4_review

  1. 1. PART IV BOARD REVIEW 1FOUR LETTERS IN LANGUAGE OF RADIOLOGY:1. GAS: IS BLACK2. FAT: IS BLACK3. MUSCLE, WATER AND SOFT TISSUE: GREY4. BONE OR METAL: IS WHITENEVER SAY “IT LOOKS LIKE ” ALWAYS SAY “IT APPEARS TO BE ”How to take the test:1. Read case history . AGE is the most important2. Scan the answers3. ID views present4. Two motive questionsa. What is the office motive? DDX? Or routineb. What is the color motive? (penetrated or over penetrated)! MOTIVE IS MY FRIEND; MOTIVE WILL GET ME A LICENSE!Te view if contraindicated for fracture or infection---choose another answerColor Motives:1. Bone is white, soft tissue is GREY2. Black is /gas or Fat3. Routine colors = Bone is white, soft tissue is white, view is under penetrated4. If you can ’t see it, you can ’t Dx it!5. Bone is Dark, soft tissue is dark . film is over penetrated, worry about what you can see- チªADI space6. Bone is grey and soft tissue is grey = osteopenia = loss of bone densitya. Hypothyroidismb. Multiple myelomac. Pencil thin cortex7. Bone is white, soft tissue black = Bone Dx (チ«KVP by 15%,double MAS)8. Soft tissue is whiter (チªKVP 15%,MAS チ«½)1 st impression is . AM I DISTRACTED FROM READING FILM2 nd impression . IS IT CONGENITAL, ACQUIRED OR NOT SUREIMPORTANT!ONCE YOU HAVE A CONGENITAL ANOMALY ON THE FILM, NO LONGERWORRY ABOUTALTERATIONS OF COLOR, MALIGNANCY, PAGET ’S, INFECTION, NOSUBTLE FX ’S OR SUBTLEDISLOCATIONSCHECK FOR DEFORMITY AND AGE:- bending or twisting of the bone with the cortex intact = congenital anomaly or paget ’sdz- last place to ossifyUnder the age of twenty . not ossified yetOver the age of twenty to 40 years of ageOver the age of 40 years of age . DJDCheck ADI space- spinal laminar junction of C1
  2. 2. PART IV BOARD REVIEW 2- front of bodies- base of dens for radiolucent line- approximate dens for height, alignment and color- vertebral bodies . alteration of color and shape- disc space . size and color alteration- arch of C1- pedicle of C2- back of bodies . pedicle and facets- spinal laminar lines and spinouses- soft tissue in front of vertebral bodiesCervical spine lateral view:- ADI space . adult = 3mm, Child = 5mm (under age 13)- If you see ADI rule out agenesis- If you see ADI is the width of the anterior tubercle check spinal laminar junction of C2- position of C1 on C2Anterior to the Spinal laminar junction of C2 could for 4 reasons:1. Fractured Dens = Trauma2. Increased ADI space = RA3. Unstable Os Odontiodium = congenital4. Agenesis of the DensPosterior to the Spinal laminar junction of C2 could be for three reasons:1. Fractured Dens2. Agenesis of the Dens3. Unstable Os OdontoidiumC1-C2Atlas anterior means:1. Increased ADI = congeneital or acquired causesa. Down syndrome patients may have missing transverse ligamentb. Take flexion and extension x-rays for stability before adjusting or letting child competeinspecial olympics (?)Acquired:1. RA2. Trauma3. AS4. Psoriatic - PA5. Reiters syndromeINFLAMMATION IS WHAT THEY ALL HAVE IN COMMON SO LOOK FOR THEFIVE SIGNS +LOSS OF FUNCTIONQ: so during the test ask yourself, is this inflammatory, does this effect the spine?
  3. 3. PART IV BOARD REVIEW 3Lateral cervical spine:1. Anterior syndesmophytes = Inflammatory arthritis2. Marginal syndesmophytes = Ankylosing spondylitis3. Non- Marginal syndesmophytes = Reiters or Psoriatic4. Hyperostosis = candle wax dripping appearance of three or more vertebra with discspaces preserved =DISH aka Forrestiers Dz or AS5. Lipping and Spurring = DJD or Infection6. Compression or Avulsion fracture7. Syndesmophytes are an inflammatory spur . loss of functionPneumonic for HLA-B27 positive arthritidis:- P = Psoriatic arthirits- E = Enteropathic arthritis- A = Ankylosing spondylitis- R = Reiter ’s Dz = Males 20-30 yoa, conjunctivitis, urithritis, arthritis, Heel pain =Lovers heelDISH OR HYPEROSTOSIS:- fibrous dysplasia . mosaic (doesn ’t exist)Type 2: Non-MarginalAnterior syndesmophyte -Innateresponse to inflammation to protect thespinal cordPsoriatic arthritis . RA neg.Reiter ’s Dz . RA neg.Type 1: Marginal syndesmophyte -Innateresponse to inflammation toprotect the spinal cord, effects thefibers of annulus fibrosis of the disclooks likeEGG SHELL CALCIFICATION of thediscAnkylosing Spondylitis . akaMarie Strumpel dzDJD:- Lipping or spurring- Eburnation or subchondral sclerosis, spondylosis- Endplate whitening or thickening- Cause is subluxation or poor mechanicsCOMPRESSION OR AVULSION FRACTURES:- Tear drop fractures- Same size as the piece that is missing, any level of the spineNew Step:Base of the dens there appears to be a radiolucent line across (horozontal)1. Fractured dens
  4. 4. PART IV BOARD REVIEW 4a. Radiolucent w/o cortical margins or sclerosisb. Jagged and roughened edgesc. Displacement of the dens posterior or anterior (tilted)2. Os Odontiodiuma. Radiolucency that is smooth with cortical margins or sclerosis on each side of theradiolucency3. Agenesis of the Densa. No ADI spaceb. Radiolucency of the bone of the dens, compare the body of C2 with where the Densshould be,same color if dens is missing, brighter or whiter ’ if dens is therec. Approximate the dens for height, alignment and color . Dens should be same height asthe bodyof C2d. Should be below the level of the occiput or it is called basilar invagination or basilarimpressione. Caused by softer weak bones like, Paget ’s dz, Trauma , osteomalacia or Fibrousdysplasiaf. Use Chamberlains line or Macgregor ’s line (females 10mm, males 8mm)4. Mach line (RO the rest)a. Overlapping of structures, when all is aligned properlyAlignment of the Dens:1. Width of the C2 body through the C1 anterior and posterior tubercles2. Color: if no ADI spacea. Penetrated = darkb. Not penetrated = light3. Rule:a. Any displacement from bone from itself = assume fracture until otherwise provenb. Signs of a non-union :i. Smooth radiolucencyii. Obvious cortical margins and sclerosis around un-united pieces4. Or office motive like “the reason a flexion/extension series was done ”STABILITYTEST: Linear tomogram . tube moves around patient in order to block out unwantedstructuresFracture of the Dens: Use a Philadelphia color to support until patient can get to Hospitalfor surgical correctionOS ODONTIODIUM:1. Take flexion and extension films to check for stabilitya. if stable = adjustb. if unstable = refer out2. Usually the anterior tubercle is larger then the posterior tubercle due to stresshypertrophya. Suggests long standing weight bearing changesb. Usually congenitalc. Long standing Rheumatoid arthritis
  5. 5. PART IV BOARD REVIEW 5BODIES:1. Alteration of color and alteration of shape2. If vertebral body is dark = lytic metastasis or multiple myeloma3. If vertebral body is whiter ’ = Blastic metastasis or Paget ’s dzRULE: ANYTIME YOU SEE WHITE DENSITY IN THE BONE OTHER THEN THEHEADS OF THEFEMURS OR THE CARPAL BONES ASSUME BLASTIC METASTASIS . UNLESSOTHERWISEPROVEN BY LABSHeads of the femurs = avascular necrosis or DJD- Carpal bones = avascular necrosisLabs:- Alkaline phosphatase チª= Blastic MetastasisBone Scan:- Blastic metastasis = appears HOT (cold is normal)Biopsy: + yes, - noRULE OUT BLASTIC METASTASIS BY: 1. Age 40 and above2. Other radiographic signsa. Cortical thickeningb. Enlargementc. DeformityPAGET ’S DZ – PICTURE FRAME VERTEBRA3. Alteration of shape:a. Paget ’s dzb. Fracturec. Congenital anomalyFOUR X-RAY STAGES OF PAGET ’S DZ:1. Destructive or lytic stage2. Combined stage (lytic and blastic activity)3. Sclerotic or healing stage4. Malignant stage5. Most common is OSTEOSARCOMA aka OSTEITIS DEFORMANS6. COTTON WOOL APPEARANCE OF PAGET ’S7. CRISS CROSS OF TRABECULAR PATTERN . COURSE TRABECULARPATTERN,FASCICULATION ’S, SHEAVE ’S OF WHEAT APPEARANCEBlastic metastasis:- over the age of forty- チªdensity- Ivory white vertebral body- SNOW BALL APPEARANCE- NO CORTICAL THICKENING- NO PERIOSTEAL REACTIONPaget ’s dz:
  6. 6. PART IV BOARD REVIEW 6- Over the age of fifty- チªsize or cortical thickening- Enlargement or deformity- Ivory white vertebral bodyHodgkin ’s dz:- 20-40 years of age- Ivory white vertebral body - Anterior body scalloping due to lymphnode erosion- Less then 5% of bone involvementFracture:- Loss of anterior body height of 25% or more- Posterior height normal = trauma- Posterior height decreased = Pathologic malignancyALTERATION OF SHAPE:Can be either Congenital or AcquiredAcquired fusion of the facets = Rheumatoid arthritis or Ankylosing Spondylitis- AS will have marginal syndesmophytes- RA . never effects the bodies or the discs, only the synovial jointsDISC SPACES:Loss of disc spaces can be from:1. DJD akaa. Degenerative joint diseaseb. Spondylosisc. Osteoarthritisd. Lipping and spurringe. Eburnation (boards)f. Subchondral sclerosis2. Infection:Congenital block vertebra = Wasp Waist VB- Non-segmentation- Failure of segmentation- Multiple blocks = Klippel Feil syndrome- Remnant or Rudimentary discs- Fused Spinous processes- Two spinouses with one spinal laminarjunction lineAcquired Block vertebra: Surgical or disease- Fusion with anterior bridging . candlewax appearance- Not sure by front of bodies check facets- Two spinous with two spinal laminarjunctionsa. Disc changes in size or colorb. Destruction of both endplates surrounding the discALTERATION OF SIZE:- Paget ’s
  7. 7. PART IV BOARD REVIEW 7- Fracture- Congenital anomalyBlack = gas = vacuum phenomenon or cleft sign- caused from DJD or trauma . degenerative disc d- aka Knudsen ’s phenomenonDisc infection:- Lipping and spurring- Destroyed endplates- WBC 5-10 thousand = normalo 11-25 thousand = infectiono 25-50 thousand = severe infectiono over 50 thousand = leukemia- No blood supply- Infection of bacteria due to poor immune system . REFER to ERMalignancy:- eats, reproduces, doesn ’t workA-P FILMS: read bottom-up1. T1 . TP ’S point up2. C7 . TP ’S point down3. 1 st ribs = bone articulation with bone4. Look for hypertrophic/elongated TP ’S5. Rule out Cervical ribs, bone articulation with bone, line of demarcation6. C7 . elongated TP ’S = not attached to another structure, just longer7. Thoracic outlet syndrome = Do HALLSTEAD ’S TEST (boards question)Vertebral bodies:1. Check from the bottom-up for color, size and shape2. Check Vertebral body to the disc space3. Check unco-vertebral jointsa. Joints of Von Luschab. Uncinate processesc. If they bend laterally = arthrosisd. Creates a Mach line on lateral films Hemispherical spondylosclerosise. Half moon shapeSpinae bifida:- will have smooth cortical margins around un-united pieces- - Bifid spinouses- Missing spinouseso CongenitalC Agenesiso AcquiredA Lytic MetastasisL Trauma . must see trauma elsewhere or history says accidentm Vertebral plana = pathology
  8. 8. PART IV BOARD REVIEW 8P InfectionI No endplates = destroyedN Decreased body heightNO ARCH OF C1:- Congenital . agenesis = do motion studies, flexion and extension- Acquired . Lytic Metastasis = teeth marks- Check arch of atlas for equal space between theocciput and the spinous f C2- Then check for jagged, rough edges or corticalmargins- Rule of bone displaced from bone = fracture- Vertical radiolucency = fracture- Non-union . smooth cortical margins and un-unitedpieces = non ossificationsPosterior ponticus: aka Arcuate foramen, bridge- calcification of the atlanto-occipitalmembrane- Vertebral artery and C1 nerve run through it- ACQUIRED . do Maine ’s test, Georges testor Deklynes tests for VBI insufficiencyVERTEBRAL BASILAR ARTERY INSUFFICIENCY:- Smoker 20-30- Women on birth control pills- Drugs- Do not use diversified techniquePEDICLE OF C2:1. Radiolucency of arch of atlas2. No growth centers in the pedicles3. Has to be a fracture . Hyperextension injury or Hangman ’s fractureINTERRUPTION OF PRIMARY GROWTH CENTERS:1. Vertebral body = Butterfly vertebra or Hemi vertebra2. Lamina = Non-union, Spinae bifida, Agenesis3. Arch of the atlasINTERRUPTION OF THE SECONDARY GROWTH CENTERS:1. Subchondral = under the endplates2. Transverse processes = un-united . Schermannes dz3. Tip of the spinous- un-united spinousButterfly vertebra . Receded endplatesR defect in primary growth centers of endplatesd Long spinous process25% or more are pathologic fractures- Multiple Myeloma- Metastasis to the bone
  9. 9. PART IV BOARD REVIEW 9METASTASIS:- A-P film pedicle is missing- HOT bone scan- ªAlkaline phosphataseMULTIPLE MYELOMA:- COLD bone scan- Reverse A/G ratio in labs- IgG チª= Immunophoresis- Bence Jones Proteinuriao Abnormal proteins in the urine (any protein in urine is abnormal)SHAPE OF THE BODY:1. Vertebral plana = flat vertebral body, posterior and anterior body (pathologic)2. Pancake vertebra = flat VB3. Silver dollar VB4. Coin edge VB5. Wrinkled VBALIGNMENT: SUBLUXATION:1. Bottom up = all2. 10% slippage of VB anteriorly or posteriorly with facets aligned3. Check Georges line = bottom to top4. DISLOCATION:1. Top . Down2. 25% or more with facets perched and spinous fanningFACETS DISLOCATIONS:TEARS-1. Ligamentum nucha2. Inter-spinous ligament3. Ligamentum flavum (1 st )4. Capsular ligament (2 nd )Abnormal space between spinouses = Fanning = Brace 1 st , ER 2 ndSPINAL CORD DAMAGE:1. FACETS ARE DISLOCATED- TRAUMA2. FACETS ARE DESTROYED . ARTHROSIS OF DJD3. FACETS ARE FUSED .a. CONGENITAL = 2 facets, 1 spinal laminar linesb. ACQUIRED = 2 facets, 2 spinal laminar linesi. Ankylosis Spondylitisii. Rheumatoid arthritis1. Rat bite erosionsiii. Whitening of the joints = Arthritis or DJDIVF ON LATERAL FILM: Motive1. Over rotation of facet ’s2. Neurofibroma . enlargement, posterior body scalloping 2. Fusion
  10. 10. PART IV BOARD REVIEW 10C1 Spondyloschesis = looks like snake- Cleft of C1 spinous- Non-union- Absence of spina bifida- Prevention is folic acid during pregnancySPINAE BIFIDA OCULTA aka SPINAE BIFIDA VERA aka SPINAE BIFIDAMANIFESTA- PROTRUSION OF THE SPINAL CORD THROUGH ABSENCE OF SPINOUS- Not usually seen in chiropractic due to birth defect and poor outcomeAcquired Spinae Bifida:- Removed = laminectomy- Eaten from Metastasis- Fractured . C6, C7, T1 = Clay Shovelers fractureo Forced hyper-flexion injuryo Do flexion and extension films to check stability- Agenesis of the spinous = congenitalSOFT TISSUE IN FRONT OF BODIES:- Pharynx . to C4 from Nose and Mouth- Larynx - At the level of C5- Trachea . C6 down- Retro-Pharyngeal interval = < 7 mmo Increased by trauma, infection or malignancyo Never larger then the vertebral body width- Infection:o Osteomyelitiso Infectious Spondylitiso Infectious arthritiso Septic arthritiso Tuberculosis = Pott ’s dzo DiscitisRULE FOR LATERAL CERVICAL SPINE:“I WILL NOT PICK INFECTION ON LATERAL CERVICAL FILM WHEN SOFTTISSUE IS PRESENT,UNLESS IT IS SWELLING ”ANKYLOSING SPONDYLITIS:- Starts between 15 and 35 YOA- LBP with morning stiffness- SI joints:o 1 st then moves up the spine (bilateral sclerosis)o Pseudo-wideningo Erosions and sclerosis (Star Sign)o Fused SI joint (Ghost Joint)o Early- shiny corner sign of SI joint- T12 . L1 arch starts
  11. 11. PART IV BOARD REVIEW 11o Bi-lateral marginal syndesmophyteso Bamboo Spine appearanceo Dagger sign (fused spinouses)o Poker spine appearance (like fire place poker)o Carrot stick fracture of VBC Not healed = Andersen lesiono Trolley track sign = Bi-lateral fused facets- Eye exams:o Iritis, abnormal exam- Abdominal aortic aneurisms common- Loss of ROM . Flex/Ext serieso ALL and PLL affected- Fused Facets . Lateral flexion and Rotation loss- Orthopedic tests:o Lewin supineo Forestiers Bowstring test- Chest expansion チ«Labs: HLA-B27, ESR, RA-Latex negative- Special test: Bone scan or MRI- Case management: Co-Treatment with Rheumatologist- Complication: Canal stenosis from ALL and PLL calcificationD.I.S.H.: Diffuse Idiopathic Skeletal HyperostosisAka Forestiers Dz, Ankylosing hyperostosis- Men over 50 YOA- Diabetes Mellitus . correlations with Eye exam- Spinal pain and stiffness- Loss of extension and flexion- Lateral flexion and Rotation preserved- X-ray:o Hyperostosis . Candle Wax Drippings of 3 or more segments, disc space preservedo Never facet ’s (posterior preserved)o Anterior bridging- Labs for DISH:o HLA-B8o Test blood glucose (DM) - Case management: Adjust facetsFLEXION AND EXTENSION FILMS: Davis seriesMOTION STUDIES aka Stress FilmsMOTIVE:1. Abnormal motion or fusiona. Ligament stabilityb. Taken usually due to RAc. ADI space should never change for any views2. Contraindication:
  12. 12. PART IV BOARD REVIEW 12a. Cervical fracture (except Clay Shovelers Fx )b. Traumatic dislocationc. All malignancies or infectionKLIPPEL FEIL SYNDROME:- Multiple wasp waist vertebral bodies- Sprengles Deformity of the scapula- Omo-vertebral bone = fusion of the scapula to the C7VB- Occipitalization of C1A-P OPEN MOUTH: motive- View Den ’s and Atlas- Rule out fracture- 8 x 10 film1. Check the Den ’s to see if it is there2. Find structures that create mach lines:a. Occiputb. Teethc. Arch of atlasd. Posterior arch = looks like smilee. Anterior arch = looks like frown3. Base of Den ’s ;a. Look for radiolucent line at baseb. Trace the Den ’s . is it in place4. Check Para Odontoid spaces5. Check lateral masses for overhanging6. Check TP ’S of C1 for congenital anomaly7. Check for alteration of color and shape8. Check disc spaces of C2-C3, C4-C59. Check spinouses for bifurcation10. Check soft tissue around the jawOver hanging means the Atlas is fractured . Burst fracture (Hangman ’s Fx)- Look for patient to present with RUST SIGN (holding neck from moving)OS ODONTOIDIUM: Congenital1. Big thick radiolucent line at the base of the Den ’s2. Den ’s is leaning or tilting = fractureTypes of fractures of theDen ’s:Type 1 fracture: Tip of theDen ’sType 2 fracture of the Den ’s:- Base of the Den ’s- Big thick radiolucent lineType 3 fracture of the Den ’s:- Body of the Den ’sA-P LOWER CERVICAL SPINE:- TAKEN WITH 15° TUBE TILT
  13. 13. PART IV BOARD REVIEW 13- EPI-TRANSVERSE PROCESSES = TP ’S -STRAIGHT UP- PARA MASTOID PROCESSES = TP ’S -UP AND LATERAL- PARACONDYLAR PROCESSES = TP ’S- UP AND MEDIAL - SOMETIMES THEY MIMIC JEFFERSON FRACTURESRULE:“NEVER GIVE BLASTIC METASTASIS AS AN ANSWER ON C2 ”“NEVER GIVE SPINAE BIFIDA AS AN ANSWER ON C4(NARROWING OF TRACHEA)1. CHECK TP ’S OF T1 AND C72. CHECK VERTEBRAL BODIES FOR COLOR AND SHAPE3. CHECK DISC SPACES AND UNCINATES FOR ARTHROSIS4. CHECK SPINOUSES FOR SPINAE BIFIDA OR FRACTURES5. CHECK TRACHEAL AIR SHADOW FOR DEVIATION6. CHECK SOFT TISSUES BILATERALLY OF THE SPINE (SWELLING, TUMORS,LYMPHADENOPATHY)TRACHEAL AIR SHADOW:- DEVIATION OF THE TRACHEA- CAUSE:O ATELECTASIS = SUCKS TO THE SIDE OF COLLAPSED LUNGO SOFT TISSUE SWELLING OR TUMORO MOST COMMONLY = ENLARGED THYROID GLAND- CHECK SOFT TISSUE BILATERALLY:O LYMPH NODE CALCIFICATION (WHITE)O VASCULAR CALCIFICATION (2 OR MORE LINED UP VERTICAL)V CAROTIDSC C3-C4 AREACERVICAL OBLIQUE:1. IVF ’S FORM TOP DOWN = SIZE AND SHAPE (FIGURE EIGHT)2. 15° TUBE TILT . CAUDAD . ANTERIOR3. 15° TUBE TILT . CEPHALID . POSTERIOR4. PNEUMONIC:- C - CERVICAL- O . OPPOSITE IVF ’S- P . POSTERIOR5. ONE MARKER SYSTEM FOR X-RAYS- FRONT OF SPINE = LEFT POSTERIOR OBLIQUE IS RIGHT IVFBOUNDARIES:- FRONT OF BODIES AND UNCINATE PROCESSES- SUPERIOR AND INFERIOR FACETS- PEDICLESRULE for CERVICAL OBLIQUE: “NEVER PUT OCCIPITALIZATION AS ANANSWER ”MOTIVE FOR TAKING OBLIQUES:- IS APPEARANCE IVF ’S
  14. 14. PART IV BOARD REVIEW 14- C3-C4 SEGMENT = C4 NERVE . C3 DISC- SMALLER :O PROTRUSION FROM FRONT . UNCINATE PROCESSESO PROTRUSION FROM POSTERIOR . FACET ARTHROSISO BOTH AKA IVF ENCROACHMENT = HOURGLASS APPEARANCEBIGGER CAUSED BY:1. NEUROFIBROMAo 2 IVF ’S one big forameno Erosion and posterior body scallopingo Dumbbell shaped IVFo Associated with Café ’ A ’lait spots on skino Coast of California appearance . smootho Fibrous dysplasia . Coast of Maine appearance . jagged edge2. Agenesis of the pediclesLATERAL THORACIC ’S:1. Read from top-down2. Check for DJD, Osteophytes3. Any time anterior body height is decreased 50% or more = Traumaa. Osteoporosisb. Infectionc. MalignancyTrauma:= PATHOLOGY- INFECTION = NO ENDPLATES= COMPRESSION OF ANTERIOR ENDPLATE- DECREASED BODY HEIGHT OF 10-15% = MILD COMPRESSION FRACTURE- Infection- Schermannes Dz aka ’s:o Avascular necrosis of the 2 nd endplateo Ischemic necrosiso Aseptic necrosiso Osteonecrosiso Subchondral necrosiso Osteochondrosis of the spineo Juvenile Kyphosis dorsaliso Multiple smorles defects- Males 10-16 years of age- チªKyphosis- Multiple endplate irregularities - Similar destruction- Multiple smorles nodes- Possible trauma- No labs- Special studies : MRI, Bone scan- Case management:o Stop all physical activity
  15. 15. PART IV BOARD REVIEW 15o Thoraco-lumbar braceo Non-weight bearing activities . swimmingo Self resolving . 8 months . 2 yearso Left un-treated = permanent postural deformitySIGNS OF TRAUMA:- LINE OF DOUBLE DENSITY- LINE OF CONDENSATION- ZONE OF IMPACTION- STEP OFF DEFORMITY- UPSIDE DOWN V SIGN DEFORMITYCAUSE:- HYPERFLEXION OR AXIAL COMPRESSIONLIMBUS BONE:- UN-UNITED EPIPHYSIS- PERSISTENT EPIPHYSIS-- FRACTURE = DISPLACEMENT AND JAGGED EDGES- SMORLES NODE = INVAGINATION OF THE NUCLEUS POPULOUS INTOENDPLATE - - IF TRAUMA= APPEARS SMALL AND JAGGED ON THE ANTERIOR PORTION OF ENDPLATEAka NUCLEAR IMPRESSION .Aka NOTOCHORDAL PERSISTENCY- SMOOTHAPPEARANCE- Called ” CUPIDSBOW ” on the A-P filmLUMBAR SPINE:1. Scotty dog seen on oblique view2. Pars (middle of facets) is Motive3. Break in Pars . Spondylolysis4. Spinouses are thin . don ’t worry about themSIX CATEGORIES OF SPONDYLOTHESIS:1. Dysplastic . obvious congenital anomaly2. Isthmic . break in Pars (Spondylolytic)3. Degenerative . No Break . DJD related = Non-Spondylolytic4. Traumatic . Break in pedicle5. Pathologic . disease6. Iatrogenic . surgical fusionMEYERDING CLASSIFICATION (X-5): on lateral film only- GRADE 1 = 1%-25% OF SUPERIOR BODY ON INFERIOR BODY- GRADE 2 = 26%-50% -------------- GRADE 3 = 51%-75% -------------- GRADE 4 = 76% - 100% ----------- OVER 100% SLIPPAGE = SPONDYLOPTOSIS (complete)
  16. 16. PART IV BOARD REVIEW 16- Napoleons hat sign akao Inverted napoleon hat signo Bowline of brailsford - o Le jean denauv flapSOFT TISSUE OF LUMBAR SPINE:MOTIVE:1. Calcification of the abdominal aortic artery = Atherosclerosis2. Abdominal aortic aneurism . contraindication to adjust > 3.8 cm (38mm) less thenwidth of VBa. Curvilinear calcificationb. Aortic dilationc. Fusiform shape3. TESTS:a. Ultrasonography or Diagnostic Ultrasoundb. Refer to Vascular specialistc. Surgery indicated if greater then 5cm (50mm)4. S/S:a. Hypo-volumic shock and death = worst scenarioRENAL ARTERY ON LUMBAR SPINE VIEWS:- level of L2 VB- Cheerio appearance (donut) = Renal artery calcificationLipping and spurring with sacrum andSPONDYLOLISTHESIS = called BUTTRESSINGCase management:- take oblique and flexion and extension viewsfor stability before adjusting - - If unstable refer out to orthopedistObliques . are read from top-down to view pars, facets, Scotty dogMarking system on x-rays: pneumonic- L . Left- A . Anterior- O- OppositeCollar sign: Break in the Pars = SPONDYLOLYSISRPO:- right pars, pedicle and inferior and superior facets- left tail = TP- left leg = Inferior facetLines to Measure . Hadley ’s S curve or McNabs line (in notes)Measured from L5-L4 upLATERAL SACRUM:USE EXTREMITY PROCESS:1. PERIOSTIUM2. CORTEX3. MEDULLA (MEDULLARY CORTEX)4. JOINTS
  17. 17. PART IV BOARD REVIEW 175. GROWTH CENTERS6. SOFT TISSUEL4Whiter ’ = Facet arthrosisFacet Imbrication = loss of disc height - DJD or SubluxationLUMBAR SPINE A-P ERHART BLOCKHEAD VERTEBRA SYSTEM:1. PEDICLES . EATEN AWAYa. REMAIN WITH COLLAPSED VBb. AGENESIS OF THE PEDICLE OR LYTIC METASTASIS2. TP ’S . FRACTURED OR NON-UNION3. SPINOUS . ABSENT, EATEN = TEETH MARKS, SURGERY, CONGENITALANOMALY4. BODY:a. CORDUROY APPEARANCE = HEMANGIOMAb. BUTTERFLY . CONGENITALc. WING OF BUTTERFLY . HEMI VERTEBRA = CONGENITALd. WHITER = BLASTIC METS OR PAGET ’S DZ = LARGER AND WHITERe. DARKER = LYTIC METS OR MULTIPLE MYELOMAf. CRUSHED BLOCKHEAD = COMPRESSION FRACTURE OR PATHOLOGYi. MALIGNANCYii. MULTIPLE MYELOMAiii. METASTASISA-P LUMBAR SPINE:- Not diagnostic for SI joint pathology- Upper 1/3 of SIJ is cartilage- Lower 1/3 of SIJ is synovial- 1 st - Check lower 1/3 of SIJ to the other SIJ- 2 nd -Check Ilium to the other Ilium for color, shape or Reisner sign (growth center)- 3 rd . Find L4- 4 th . Find 12 th rib and count down from T12 to L5 for sacralization or lumbarization- 6 th . L5 . SI for facet tropism (orientation difference)- 7 th . square block heads (VB ’s) and disc spaces all the way up- 8 th . Abdominal aortic aneurism- 9 th . Renal artery calcification or aneurism- 10 th . Soft tissue from ribs to the iliac crest - - 11 th . Soft tissue in the pelvic inletSI JOINT CONDITIONS:- AS . BILATERAL FUSION OF THE SIJO 1 ST SIGN OF AS- OCI . SCLEROSIS BILATERALLY ON THE ILIAC SIDE (NOT THE SACRALSIDE)O COMMON IN MULTIPARITY WOMENO COMPARE THE UPPER ILIAC COLOR WITH THE LOWER SACRALCOLORO SELF RESOLVES OVER TIME
  18. 18. PART IV BOARD REVIEW 18- DJD . SCLEROSIS ON BOTH SIDES OF JOINTO HYPEROSTOSIS TRIANGULARISO OSTEITIS TRIANGULARISANGULATED SPOT TO VIEW SIJ, WITH 20° ANGULATED TUBE TILT- MAKES THE INLET APPEAR LIKE ANIMAL EARS- ONLY ONE SIDE WITH COLOR CHANGE = BLASTIC METASTASIS- CHECK ILIA FOR ALTERATIONS OF COLOR, SHAPE AND REISNER SIGN IFNECESSARY- COLOR . WHITE = PAGET ’S, BLASTIC METASTASISO DARK = LYTIC METS, MULTIPLE MYELOMA, BENIGN BONETUMOR- SHAPE: LIKE EXTREMITIESO P . PAGET ’S DZ = WHITER ’ AND LARGERO F . FRACTURE = BONE DISPLACED FROM BONEO F . FIBROUS DYSPLASIA- DARK DENSITIES:O LYTIC METASTASIS . PUNCHED OUT LESIONS, SWISS CHEESEAPPEARANCEO PAGET ’S DZ . PROTRUSION ACETABULIO RUFFLED SHAPE OF RAMIIR ALTERATION OF SHAPEO FRACTURE . BILATERAL BREAKS OF THE ILIUMO FIBROUS DYSPLASIA . ABNORMAL SHAPEREISNER SIGN:1. SCOLIOSIS . MONITOR OSSIFICATION OF BONES2. NO AGE GIVEN ON HISTORYA. GROWTH CENTERSI. OPEN .UNDER AGE 20II. WHITE LINE . 20-30 YEARS OF AGEIII. NO GROWTH CENTER . OVER AGE 30IV. NO GROWTH CENTER WITH DJD . OVER 40 YEARS OF AGEFIND L4 AND THE 12 TH RIB:- CHECK FOR LUMBARIZATION OF THE SIJ- L5 TP FULLY FUSED OR ARTICULATED WITH SACRUM =SACRALIZATION OF L5 - O LUMBOSACRAL TRANSITIONAL SEGMENTO SCLEROSIS OF L5 TP ON THE INFERIOR ASPECT = ARTICULATIONO PSEUDO-SACRALIZATION =ARTICULATEDO PSEUDO-ARTHROSISO ACCESSORY JOINTO UNILATERAL SACRALIZATION = ONESIDE ONLYO SPATULA TP = NO SCLEROSIS
  19. 19. PART IV BOARD REVIEW 19SACRUM: ALTERATION OF COLOR AND SHAPE AND FOR SPINAE BIFIDAAND KNIFECLASP DEFORMITY- P . PAGET ’S DZ- F- FRACTURE- C- CONGENITALO VERTICAL RADIOLUCENCYV SPINAE BIFIDA = NO LAMINA, SPINAL CORD EXPOSEDS KNIFE CLASP DEFORMITY = L5 SPINOUS ELONGATIONK HYPEREXTENSION AGGRAVATES THIS CONDITIONO F . FIBROUS DYSPLASIACHECK L5-SI FOR FACET TROPISM –ASYMMETRICAL = CAUSES LBPHemi vertebra comes in two types:1. Segmented2. Non-segmented- Either one causes scoliosis- Congenital = scrambled spine appearance- 2 pedicles = pedicle duplication sign- Defect of the primary growth center - - Important to rule out trauma or malignancyPEDICLES:1. Agenesis of a pedicle = Whiter appearance-compared to the pedicles above and below(チªuse)2. Malignancy = surviving pedicle is the same color as the one above and below (lyticmets)TRANSVERSE PROCESSES:1. BENIGN TUMOR = Increases the size of the TP2. < 20 YOA . ABC . aneurismal bone cyst3. > 20 YOA . GCT . Giant Cell Tumor4. 10-30 YOA . Osteoblastoma5. Fracture = displaced6. Non-Union = in correct positionQuestions: List two complications to the condition you see? Fractured TP ’S1. Kidney contusion . Blood in urine2. Torn ureter . Uremia = blood in bloodSPINOUS:1. EATEN . Color change, teeth marks2. SURGERY- Artifacts . laminectomy3. CONGENITAL- Othera. Surgical fusion = Arthrodecisb. Pathological fusion = Ankylosis4. Spinae bifida occulta . know for Chiro CaseDISC SPACES:
  20. 20. PART IV BOARD REVIEW 201. DJD . bamboo spine = Ankylosing Spondylitis2. Infection and syndesmophytes3. Reiter ’s or PsoriaticSCOLIOSIS:SP ’S TOWARD CONVEXITY = Simple Scoliosis SP contact1. Idiopathic adolescent scoliosis2. largest convexity of curve3. SP ’s toward concavity = Rotary Scoliosis4. Never contact the spinousThoracic spine Soft tissue comparison:BONE: DISC:WHITE WHITE . UNDER PENETRATEDWHITE BLACK . BLASTIC METASTASIS1 ST : Abdominal aortic artery on A-P LS2 nd : Renal arteries at the level of L23 rd : Abdominal aorta at the level of L2-L4 (never see on A-P unlessThere is an aneurism to the right and left of spine) called a curvilinear - calcificationWhat to look for in the soft tissue:1. COLOR:a. Whiter then bone . metal artifactb. Shaped like spots or spotty appearance = heavy metal injectionc. Gold for RAd. Mercurye. Arsenic for syphilis2. LOCATION:a. Neural canal or inter-vertebral spaces = remnants of myelogram (white density)b. Esophagus or stomach = Upper GI . barium swallowc. Colon or rectum = Lower GI . Barium enemad. Kidney, ureter or bladder = IVP study or KUB = intravenous pyelogram (Yochum)e. Gall stones = cholelithesis, female, forty, fertile, flatulent with floating fleecing fecesi. Pain in the right shoulder on right scapulaii. L1-L2 location of Gallbladderiii. Not visible on x-ray 90% of the time, due to being made of cholesterol or fat with acalcium outer layeriv. Appearance of grapes on the vine, marbles, corn nutsv. Need contrast media to see gallstones = Telopaque tabletsvi. DDX from Renal artery calcification or Gallstonesf. NEPHROLITHIASIS is a kidney stonei. Flank pain and groin pain if in uretersii. 90% are visible on plain film x-ray because they are made of calcium urate, calciumoxalate or calcium phosphateiii. Better to Dx on lateral filmg. STAG HORN CALCULUS . calcium of the renal calyces (reindeer horns appearance)i. DDX vs. Contrast media is also in the ureters (IVP)
  21. 21. PART IV BOARD REVIEW 213. AGE4. SHAPE5. SEXRIBS: read from top down, two at a time and the spaces betweenFRACTURE OF THE RIBS = 98% ON THE BOARDSTUMORS 1% =- FIBROUS DYSPLASIA- MALIGNANCY- MULTIPLE MYELOMA- LYTIC METASTASISPOSTERIOR RIBS . DOWN AND AWAY FROM SPINEANTERIOR RIBS . DOWN TOWARD THE SPINELOOK FOR BONE DISPLACED FROM BONE = FRACTURE OF THE RIBCOSTOCHONDRAL CALCIFICATION . CALCIFICATION OF THE RIBS AT THECARTILAGE INBETWEEN (NOT PATHOLOGICAL)- 1-7 RIBS ATTACH AT THE STERNUM - - 8-10 ATTACH TO CARTILAGEPELVIC INLET SOFT TISSUE:- MOST COMMONLY BENIGN TUMOR- UTERINE FIBROID TUMORO UTERINE FIBROMAO UTERINE FIBROID CYSTO LEIOMYOMA- MALES: CALCIFIED PROSTATE = CRUMPLED TINFOIL APPEARANCEPROSTATIC CARCINOMA:- MOST COMMON CAUSE OF BLASTIC METASTASIS IN MALES- > 50 YOA- BOGGY TENDER PROSTATITIS, HARD AND NODULAR CARCINOMA- URINARY FREQUENCY, URGENCY, STREAM DYSFUNCTION- LARGER PROSTATE BUT NOT TENDER = BENIGN PROSTATICHYPERTROPHY- LABS: チªPSA FOR ALLO RUPTURED CAPSULE = チªACID PHOSPHATASEO METASTASIS TO BONE = チªALKALINE PHOSPHATASEDIVIDE THE PELVIC IN HALF, WITH A SUPERIOR AND INFERIORPORTION:- SUPERIOR AND INFERIOR CALCIFICATION = VERTICALLY LINED UP =URETER STONES- SUPERIOR OR INFERIOR CALCIFICATION = COLLECTIONS OF DEPOSITSOR WHITE SPOTS = PHLEBO-LITHS, FECAL-LITHSEXTREMITIES:MOTIVE FOR EXTREMITY FILM:1. PAIN AND DYSFUNCTION2. READ PROXIMAL TO DISTAL ANATOMICALLY
  22. 22. PART IV BOARD REVIEW 223. ATYPICAL VIEW MOST LIKELY DUE TO TRAUMA4. PARTS OF BONE:a. PERIOSTIUMi. LOOK FOR PERIOSTEAL REACTION= NEW BONE GROWTH IN RESPONSETOCORTICAL DISTRUCTION1. TYPE 1 . SPICULATED = RADIATING, SUNBURST = SARCOMA OF THEBONE, OCCURS ON ANY BONE OF THE BODYa. SARCOMA IS A CANCER OF CONNECTIVE TISSUEi. OSTEOSARCOMA1. 10-30 YEARS OF AGE = ASKED ON BOARDS2. OLDER THEN 30 = THE MALIGNANT STAGE OFPAGET ’S ONLYii. CHONDROSARCOMAiii. FIBROSARCOMA1. OVER 40 YEARS OF AGEb. MOST COMMON IS MULTIPLE MYELOMA . DOES NOT CAUSE APERIOSTEAL REACTION ONLY THE MEDULLA OR CHILDREN - c. CARCINOMA IS A CANCER OF EPITHELIAL2. TYPE 2 . LAMINATED OR PARALLEL PERIOSTEAL REACTION ’a. INFECTIONi. DOES NOT EXPAND THE BONEb. TRAUMAi. DOES NOT EXPAND THE BONEc. EWING ’S SARCOMA IS POSSIBLE = NEED BIOPSY TO CONFIRM(PICK THIS IF ON TEST)i. MULTIPLE LAMINATED PARALLEL LINE ON THEDIAPHYSIS (SHAFT) OF THE BONEii. AGES 10-25 YEARS OF AGEiii. FOUND IN THE DIAPHYSIS OF THE BONEiv. CAUSES A MULTI PARALLEL ONION SKIN APPEARANCEd. MORE ADVANCED HAS A SAUCER LIKE APPEARANCE ON THEBONE (SAUCERIZATION)e. CODMAN ’S TRIANGLE = LIFTING OF THE BONE FROM THEPERIOSTIUM OVERHANGING (CODMAN ’S CUFF)f. BONE WITH PERMIATIVE REACTION OR MOTH EATENAPPEARANCE . INFECTION OR TRAUMA OR EWING ’Sg. BONY CALLOUS = HEALING FRACTUREb. CORTEXi. FOUR THINGS CAN HAPPEN TO A CORTEX1. THINNING OF THE CORTEX = OSTEOPENIA OR OSTEOPOROSISa. CRISS CROSS OF TRABECULAR PATTERN = OSTEOPOROSISi. WEIGHT TRAININGii. NATURAL ESTROGEN PRODUCTS2. THICKENING OF THE CORTEX . PAGET ’Sa. BONE DEFORMITY . PAGET ’S OR FIBROUS DYSPLASIA
  23. 23. PART IV BOARD REVIEW 233. INTERRUPTION OF THE CORTEX . FRACTURE OR NON UNION(GROWTH CENTER ONLY)4. SOFTENING OF THE CORTEX LEADING TO DEFORMITY .a. CONGENITAL ANOMALY OR PAGET ’S . IN THE SPINEb. EXTREMITIES -c. MEDULLAS (MEDULLARY)i. COMPARE OVERALL COLOR OF SOFT TISSUEii. MALIGNANT STAGE OF PAGET ’S DZ1. OVER THE AGE OF 502. BONE PAIN DEFORMITY OR ENLARGEMENT3. turns either whiter = BLASTIC mets4. TURNS DARKER = LYTIC METSIII. MORE THEN TWO VERTEBRA WITH SAME APPEARANCEIV. OF CORDUROY APPEARANCE, HEMANGIOMAV. OSTEOPOROSIS INDUCEDVI. BONE DECREASED BY ANABOLIC STEROIDSvii. WHEN SOFT TISSUE IS BLACK AND THE TISSUE IS BLACKviii. BRIGHT WHITE = EVER TIME ALL THE BONES ARE INVOLVED = - OSTEOPETROSISix. OSTEOPOIKYLOSIS- MULTIPLE TINY WHITE BONE ISLANDS ALLAPPROXIMATELY THE SAME SIZE, ASYMPTOMATICx. SEEN IN THE PELVIS, HUMOROUS, HANDS AND FEETxi. OUTSIDE THE BONE = SYNOVIAL CHONDROMETAPLASIA aka SYNOVIALOSTEOCHONDRAL MITOSES (WHITE POPCORN APPEARANCE)1. DJD2. TRAUMAd. JOINTS:i. RHEUMATOID1. EFFECTS METACARPAL PHALANGEAL JOINTS WITH DISTRIBUTIONPATTERN2. SIMILAR DESTRUCTION FROM JOINT TO JOINT3. SIGNS OF INFLAMMATION . MARGINAL aka RAT BITE EROSIONSii. OSTEOARTHRITIS1. DECREASED JOINT SPACE . GULL WING APPEARANCE OF PIP ’S2. SUBCHONDRAL SCLEROSIS3. WHITENING AROUND THE JOINT4. LIPPING AN SPURRINGP-A HAND:STEP 1 -MCP ’S, PIP ’S, DIP ’S = NEVER EFFECTED BY RASTEP 2 . METACARPAL HEADS FOR EROSIONS OR INFLAMMATIONSTEP 3 . CHECK FOR LANOAS DEFORMITY= DEVIATION OF THEPHALANGESTOWARDS THE ULNAR SIDE (WEAKNESS OF EXTENSOR MUSCLES)INDICATES INFLAMMATIONSTEP 4- CARPAL BONES FOR JOINT SPACES IN BETWEEN NO SPACES =INFLAMMATION
  24. 24. PART IV BOARD REVIEW 24STEP 5 . JUXTA-ARTICULAR OSTEOPOROSIS . LONG STANDING SIGN OFINFLAMMATION DARKNESS AROUND THE JOINTSTEP 6- AND THEN PERIOSTIUM, CORTEX, MEDULLA, GROWTH CENTERS - AND SOFT TISSUEiii. A-P FOOTiv. A-P KNEEv. HIP:1. DJD- WHITENING OF THE JOINT, CALCIFICATION2. AVASCULAR NECROSIS OF THE HEAD OF THE FEMUR . GETSWHITER BY NEW BONE GROWTH ON TOP OF DEAD BONE (ISCHEMIA)a. NO PERIOSTIUM IN A JOINT CAPSULE = LIPPING ANDSPURRING3. DJD, INFECTION OR CHARCOT ’S JOINTa. MALIM COXA SENILIS = DJD OF THE HIP = OLD BAD HIPb. SUBCHONDRAL CYST OR GEODE = SYNOVIAL FLUID IN THEBONE, OLDER PERSONBENIGN BONE TUMORSc. CHONDRAL BLASTOMA . UNDER AGE TWENTYd. GIANT CELL TUMOR . OVER THE AGE OF TWENTY4. DJD VS AVN:a. 1 ST . SUPERIOR LATERAL JOINT SPACEi. DJD . LOSS OR NARROWEDii. AVN . PRESERVEDb. 2 ND . WHITENING OF HEAD WILL BE EQUALLY TO THEACETABULAMi. AVN . ON THE FEMORAL HEAD AND NOT ON THEACETABULAMc. 3 RD . MAJOR CAUSE OF BILATERAL AVN IS CORTICALSTEROIDS, UNILATERAL IS TRAUMAd. AVN aka OSTEONECROSIS ON BOARDSe. CHILD WITH AVN = LEGG CALVE PERTHES DZ = UNDERTWENTY YEARS OF AGEe. DISLOCATEDi. TRAUMAf. DESTROYEDi. LYTIC METASTASIS OR INFECTION Erosive changes チ« - Diabetic changes チ«Rheumatoid changes チ«Gout changes チ«g. GROWTH CENTERSi. DARK LINE IN GROWTH CENTER = DARK = UNDER THE AGE OF 20ii. TIBIAL GROWTH CENTER IS WHITE = 20-30 YEARS OF AGEiii. BI-LATERAL FROG LEG VIEW OF THE HIPS1. NO DARK OR WHITE LINE BUT WHITE AREA OF DJD = OVER THE AGEOF 40h. SEX:
  25. 25. PART IV BOARD REVIEW 25i. SYMPHYSIS PUBIS = LOOK FOR PENIS OR SHAPE OF PUBIS = UPSIDEDOWNWINE GLASS OR MARTINI GLASS =MALEii. SYMPHYSIS PUBIS = LINE OF 90° ANGLE FROM OPPOSITE RAMII = MALEiii. SYMPHYSIS PUBIS FEMALE = UPSIDE DOWN MARGARITA GLASS = LINESINTERSECT AT 150° Aiv. PARA-GLENOID SULCI . MOST INFERIOR AREA OF ILIUM AND SIJ = ONLYFEMALE PELVIS ’1. OCI ON PART 4 BOARDSi. DEFORMITY = BENDING AND TWISTING OF THE BONES WITH THECORTEXINTACTi. IN THE SPINE IS1. CONGENITAL ANOMALIES OR PAGET ’Sii. IN THE EXTREMITIES1. PAGET ’S2. FIBROUS DYSPLASIA3. SABER SHIN TIBIA . BENDING OF THETIBIAa. PAGET ’Si. INCREASED OVERALL BONECOLOR OF THE MEDULLA =WHITER ’ THEN SOFT TISSUEii.b. FIBROUS DYSPLASIAi. FIBROUS TISSUE IN THEBONE = TISSUE COLOR IS SIMILAR TO MEDULLA FIND - LESSER TROCANTER COMPARE TO OTHER SIDE . IFLATERALLY BOWED AWAY FROM LINE IS CALLED ASHEPARD ’S CROOK DEFORMITYii. NOT MULTIPLE MYELOMA IF THERE IS DEFORMITY INTHE BONE BECAUSE IT EFFECTS THE MEDULLA ONLYj. SOFT TISSUE:i. BONE IS WHITE SOFT TISSUE IS WHITE1. MYOSITIS OSSIFICANS . CALCIFICATION OF THE MUSCLE BELLYa. TRAUMAb. SPORTS INJURIESc. BICEPS OF THE ARM AND THE QUADS OF THE LEGS ARE THEMOST COMMONLY AFFECTEDFRACTURES OF THE TIBIA:- SPIRAL FRACTURE- TRANSVERSE OR BANANA FRACTUREO EFFECT LONG TUBULAR BONEO SUGGESTS PATHOLOGYNON-UNION:- GROWTH CENTER OF THE BASE OF THE 1 ST METACARPAL BONE RUNS
  26. 26. PART IV BOARD REVIEW 26VERTICAL TO THE BONE- DEFORMITY . PAGET ’S OR FIBROUS DYSPLASIA- OTTO PELVIS = INTRA-PELVIS PROTRUSION OF THE ACETABULAMO MC CAUSE IS RHEUMATOID ARTHRITISPELVIS:- GROWTH CENTER OF THE ACETABULAM- FEMORAL GROWTH CENTER- ISHIOPUBIC GROWTH CENTER- GREATER TROCANTERIC GROWTH CENTER- LESSER TROCANTERIC CANT SEEo DARK = UNDER 20 YOAo CLOSE BY AGE 20o ISCHIAL-PUBIC CLOSES BY AGE 10YOUNG PATIENT:- SLIPPED CAPITAL EPIPHYSISo 10-16 YOAo SALTER HARRIS TYPE 1 FRACTURES EPIPHYSIS SLIDES ALONG THE METAPHYSISE MEASURED BY:M SHENTON ’S LINE (X-7)S KLEIN ’S LINE (X-8) BELOWIS A SLIPPED CAPITAL EPIPHYSIS, HEAD MOVES MEDIAL ANDINFERIOR THE SHAFT MOVES MEDIAL AND SUPERIOR - - OVER WEIGHT ADOLESCENT BOYSO ATYPICAL FILM = FRACTUREA REFERRAL TO ORTHOPEDIC SURGEONLEGG CALVE PERTHES:o 4-9 YOAo MORE COMMON II BOYSo TRAUMA MOST COMMONS/S HIP PAIN RADIATING INTO THE GROINo A PAINLESS LIMPo UNEXPLAINED KNEE PAIN . DUE TOCOMPENSATIONo ROM LOSS:R LOSS OF INTERNAL ROTATIONAND ABDUCTIONo ORTHOPEDICS FOR HIP AND KNEEo X-RAY FINDINGS:X FLATTENING OF THE FEMORAL HEAD
  27. 27. PART IV BOARD REVIEW 27P WHITENING OF THE FEMORAL HEAD = SNOW CAPAPPEARANCEAFRAGMENTATION OF THE FEMORAL HEAD = CRESCENTSIGNSSINCREASED JOINT SPACE= LARGER DUE TO FLAT HEADI HEALED LEGG CALVE PERTHE ’S FINDINGS:S CLOSED GROWTH CENTERC NO MORE COLOR CHANGESN NO MOREFRAGMENTATIONFDEFORMED HEAD OF THEFEMURFMUSHROOM SHAPEDEFORMITYDINTER-TROCANTERIC SAGGING = SAGGING ROPESIGN OF HEALED LEGG CALVE PERTHE ’SS NO LAB TESTSN SPECIAL TESTS = MRI OR BONE SCANS C/M: REFER TO ORTHOPEDISTS FOR BRACING = ‘A ’ BRACEB PROGNOSIS;: WORSE IS UNDETECTED, EARLY DJD AND HIPREPLACEMENT SURGERYo ATYPICAL FILMOLDER PATIENT:- PAGET ’S = OVER 50- BLASTIC METS- LYTIC METS = OVER 40- MULTIPLE MYELOMA = OVER 50- DJD = OVER 40 = LOSS OF SUPERIOR - LATERAL JOINT SPACE, SCLEROSIS OF BOTH SIDES OF JOINT- AVN = SUPERIOR JOINT LINEPRESERVED, WHITER HEAD OF THEFEMUR- OSTEOPOROSIS = ?
  28. 28. PART IV BOARD REVIEW 28- RA IN ADULT = OVER 20- HEALED LEGG CALVE PERTHES =OVER 30 YOA- BOTHCONGENITAL HIP DYSPLASIA = NO AGEo PUTTIES TRIAD = SMALL FEMORAL HEAD, SHALLOWACETABULAM, HEAD OUTSIDE THE ACETABULAMo ORTHO: ORTALANIS, CHAPELS, BARLOW ’So SURGICAL CORRECTIONDISLOCATION:- NORMAL FEMORAL HEAD- NORMAL ACETABULAM- SURGICAL CORRECTION FOR TRAUMAFIBROUS DYSPLASIA = NO AGE- PROTRUSION OF THE ACETABULAM = OTTO ’S PELVIS = RHEUMATOIDARTHRITISA-P PELVIS:- MUST COMPARE SIDE TO SIDE- 1 ST . SIJ = IF ON FILM READ THEM OR IFNOT START THERE- 2 ND . INNER PORTION OR THE PELVIC BRIM- 3 RD - OUTER PORTION OF THE PELVIS FROMTHE OUTER PORTION OF THE ILIUM TOISCHIUM MAKING SURE THE FEMORALHEAD IS IN THE ACETABULAM- 4 TH . IF FEMORAL HEAD IS OUTSIDE THATLINE = DYSPLASIA OR DISLOCATION- 5 TH . CHECK ONE PUBIS TO THE OTHER FOR COLOR AND SHAPE- 6 TH . ILIUM TO THE OTHER COLOR AND SHAPE- 7 TH . ISCHIUM TO THE OTHER FOR COLOR AND SHAPE- 8 TH - NECK AND SHAFT COLOR AND SHAPE- 9 TH . POSSIBLE EFFECT OF FRACTURESP ASIS = ATTACHMENT OF THE SARTORIUS= FLEXION AND EXTERNAL ROTATION OF THE THIGHF AIIS = ATTACHMENT OF THE RECTUS FEMORIS= FLEXION OF THE THIGH AND EXTENSION OF THELEGL ISCHIAL TUBEROSITY = ATTACHMENT OF THEHAMSTRINGHFLEXION OF THE LEG - - AVULSION FRACTURE OF THE ISCHIUM = REITER ’S BONE
  29. 29. PART IV BOARD REVIEW 29P COWBOY WITH BUTTOCK PAINC LESSER TROCANTER = ATTACHMENT OF THE PSOAS= HIP FLEXORH GREATER TROCANTER = PIRIFORMIS AND GLUTEUSMEDIUSMEXTERNAL ROTATORE ABDUCTION AND MEDIAL ROTATIONMETASTASIS - ARTHRITIC LIPPING AND SPONDYLOSISANKYLOSIS OF THE SIJAVULSION FX OF ISCHIAL TUBEROSITYINTER-TROCANTERIC FXFEMORAL NECK FXSUB CAPITAL NECK FX - SARCOMASYSTEMIC SCLEROSISKNEE:- PATELLA WILL BE WHITER ’ DUE TO THE OVERLAP- CONDYLES- ATTACHMENT FOR ANT. / POST. CRUCIATE LIGAMENTS- FIBULA .- 1 ST . LOOK INTO THE INTER-CONDYLAR JOINT SPACEo ARE THEY JAMMED INTO THE FOSSAA = DECREASED JOINT SPACE- 2 ND . CHECK MEDIAL SIDE- 3 RD . CHECK LATERAL SIDEo CLASSIC DJD . ASYMMETRICAL JOINT NARROWING . ON THEWEIGHT BEARING SIDE (MEDIAL)o ASYMMETRICAL NARROWING ON THE NON-WEIGHT BEARING SIDE= OTHER THEN DJD= ASSUME RAo MEDIAL AND LATERAL . SYMMETRICAL JOINT SPACENARROWING = RAo BOTH JOINT SPACES ARE GONE, MEDIAL AND LATERAL =SUBCHONDRAL SCLEROSIS = DJD, MINIMAL TO NO SCLEROSIS =RA- 4 TH - OSTEOCHONDRITIS DESSECANS = AVASCULAR NECROSIS OF THEDISTAL CONDYLES OF THE FEMURo 80% MEDIALo 20% LATERAL (ASPECT OF THE CONDYLE)Q: 17-30 YEAR OLD ATHLETE WITH KNEE PAIN AND KNEE LOCKS ON
  30. 30. PART IV BOARD REVIEW 30EXTENSIONo BLACK RADIOLUCENT CRESCENT SIGNo WHITER ’ UNDERNEATH THE BONE, OR MAY APPEAR NORMAL INCOLOR (2 MONTHS TO SEE AVN ON X-RAY)o BREAKS OFF = JOINT MOUSE OR OSTEOCHONDRAL BODYo TX: REFER FOR ORTHOPEDIC SURGEON- VIEW OF CHOICE FOR (OCD) IS THE TUNNEL VIEW - o MAIN REASON FOR THIS VIEW- 5 TH . PELLIGRINI STEIDA DZ= CALCIFICATION OF THE MEDIALCOLLATERAL LIG. (WHISP OF SMOKE APPEARANCE)o SEEN WITH DJD OR TRAUMA- 6 TH . NEUROPATHIC JOINT= APPEARS AS IF IT EXPLODEDo NEUROTROPHIC JOINTo NEUROGENIC JOINTo CHARCOT ’S JOINTS NO PAINN HYPERMOBIL PAINLESS JOINTH ASSOCIATED WITH 6 D ’SS DESTRUCTIOND DISLOCATIOND DENSITY INCREASED BONE DEBRISo DISORGANIZATIONo DISTENSIOND DIABETES MELLITUSD NEURO-SYPHILIS -TABES DORSALISN SYRINGOMYELIAS LEPROSYL ALCOHOLIC NEUROPATHYA CORTISONE INJECTIONS- PSEUDO-GOUT:o THE MAGNIFICATION VIEW CLEARLY DEMONSTRATES FINELINEAR CALCIFICATION OF THE HYALINE AND FIBROCARTILAGE DIAGNOSTIC OF CALCIUM PYROPHOSPHATECRYSTAL DEPOSITION DISEASEo CPPDo CHONDROCALCINOSISo ONLY IN THE KNEE ON BOARDS (DOES EFFECT OTHER AREAS)
  31. 31. PART IV BOARD REVIEW 31P FINE LINEAR CALCIFICATION WITHIN THE KNEE WITHOUT - DISTRUCTIOND WITHIN THE JOINT- GOUT:o EXCESS URIC ACID IN THE BLOODo COMES FROM PURINE BREAKDOWNo DISEASE OF DIETARY EXTRAVAGANCEo AGE OVER 50o MENSTRUATING WOMEN DO NOT GET GOUTo EXTREMELY PAINFULo 70% MONO-ARTICULAR7 BIG TOE USUALLY = PODAGRAB HOT, RED, SWOLLENH EAR EXAM FOR CRYSTALS IN THE EAR . TOPHIT X-RAY:X DESTROYS FROM OUTSIDE IN (ONLY ARTHRITIS)D JUXTA-ARTICULAR EROSIONS . OUTSIDE INO DISTRUCTION ABOVE OR BELOW THE JOINT BEFORETHE JOINT IS INVOLVEDo 30% EFFECTS MORE THEN ONE JOINT3 NO DISTRIBUTION PATTERN (SKIPS AROUND)N UNEQUAL DISTRUCTION FROM JOINT TO JOINTo LAB:L URIC ACIDU ESRE SPECIAL TESTS . JOINT ASPIRATIONo DIET: CHERRY JUICE FOR KIDNEY CLEANSED DECREASE RED MEATo COLCHICINES® FOR ACUTE GOUTC STOPS ALL DNA SYNTHESISo ALLOPURYNOL AND INDICINE FOR CHRONIC GOUT - - DON ’T TAKE DRUGS IF POSSIBLEOSGOOD-SCHLATTER DZ:- CHILDREN 10-16- KNEE PAIN THAT DOES NOT RESOLVE WITHIN THREE WEEKS- PINPOINT PAIN AND SWELLING
  32. 32. PART IV BOARD REVIEW 32- BRACE FOR OSGOOD SCHLATTER- REMOVE FROM ACTIVITY FOR THREE WEEKS- DEAD LEG SWIMMING FOR CARDIOVASCULAR TRAININGFOOT:- FRACTURE OR ARTHRITIS IS THE MOTIVE- TIBIA- FIBULA- TALUS- CALCANEOUS- LATERAL -CUBOID- MEDIAL - NAVICULARPATELLA FRACTURES:AGENESIS - FRACTURE BI-PARTITE TRI-PARTITENecrosisA-P ANKLE:E START WITH FIBULA (PROXIMAL TO DISTAL)S MOST COMMONLY FRACTURED ANKLE BONEM ONLY FIBULA FX = POTTS FXP TIBIA AND FIBULA FX = BI-MALLEOLAR FX= TRI-MALLEOLAR FX = BI-MALLEOLAR FX + FRACTURE OF - POSTERIOR TIBIA ON THE LATERAL FILMSALTER-HARRIS CLASSIFICATIONS:FRACTURES OF OPEN GROWTH CENTERS INCHILDRENA: NORMALB: TYPE 1 SALTER HARRIS- SLIPPED CAPITALEPIPHYSISC: TYPE 2 SALTER HARRIS- (MC) GROWTH CENTERAND METAPHYSISTRIANGLE PIECE = THURSTON HOLLANDFRAGMENTD: TYPE 3 SLATER HARRIS . GROWTH CENTER ANDEPIPHYSISE: TYPE 4 SALTER HARRIS . GROWTH CENTER,METAPHYSIS AND EPIPHYSISF: TYPE 5: COMPRESSED GROWTH CENTER (WORST)X-RAY BI-LATERALLY TO COMPARE VIEWS TO RO COMPRESSIONFRACTUREFOOT:- 2 ND , 3 RD , 4 TH METATARSAL FRACTURES = MARCH FRACTURES- GROWTH CENTER IN THE BASE OF THE FIFTH METATARSALo VERTICAL =NORMAL
  33. 33. PART IV BOARD REVIEW 33o HORIZONTAL LINE IS A FRACTUREH JONES FRACTUREJ DANCER ’S FRACTURE = AVULSION OF THE BASE OF THEFIFTH METATARSAL , EFFECTING PERONEUS BREVIS- CALCANEAL SPURRING:o PLANTAR FASCHIITISP LOVERS HEAL- RHEUMATOID ARTHRITISo METATARSAL JOINTS INVOLVEDo EQUAL DISTRUCTION OF THE JOINTSo LANOU DEFORMITIES . DEVIATION OF THE JOINT LATERALLYo NEVER EFFECTS THE DIP ’So JUXTA-ARTICULAR OSTEOPOROSIS- SOFT TISSUE SWELLING- LICKED CANDY STICK APPEARANCE . POINTED- GOUTo JOINT DESTROYED . NOT UNIFORMLY DISTRIBUTEDo LANOU DEFORMITYo DIP ’S DISTRUCTIONo JUXTA-ARTICULAR OSTEOPOROSISo LAB: ESR, URIC ACID- OSTEOPOROSISo DECREASED JOINT SPACE AND SUBCHONDRAL SCLEROSISo WHITER ’ - o GULL WING APPEARANCE- PSORIATIC ARTHRITIS:o INCREASED AND DARKER FROM DISTRUCTIONo BALANCING PAGODA SIGNo UNIFORM DISTRIBUTION PATTERN . ALL JOINTSSHOULDER:- EXTERNAL ROTATION VIEW = GREATER TUBEROSITY- INTERNAL ROTATION VIEW = HEAD IS ROUND- BABY ARM VIEW = RO FRACTURES, DISLOCATIONS, SEPARATIONSo WOULDN ’T BE ABLE TO DO THIS VIEW- GROWTH CENTER = DARK = OPEN = UNDER THE AGE OF TWENTY- 1 ST : WHICH JOINT CAN WE SEE BETTERo A/Co GHJ- 2 ND : CHECK THE CLAVICLE LATERAL TO MEDIAL LOOKING FORFRACTURES- LATERAL TO MEDIAL FOR SEPARATION OF THE A/C JOINT- DRAW A LINE THRU THE CENTER OF THE CLAVICLE = IT SHOULD HITTHE ACROMIUM PROCESS
  34. 34. PART IV BOARD REVIEW 34- BELOW THE LINE = A/C SEPARATION- 3 RD : COROCOID FOR TOP OF FOSSA, LATERAL BORDER OF THE SCAPULATO THE INFERIOR FOSSA- DIVIDE FOSSA INTO 25% INCREMENTS- DRAW A LINE ACROSS THE TOP OF THE FOSSA TO CHECK IF THEHUMERAL HEAD IS NOT 25% ABOVE OR BELOW THE LINE FORDISLOCATION- 4 TH : CHECK THE HEAD, SHAFT AND SURROUNDING SOFT TISSUE- 5 TH MIDDLE OF THE SCAPULA FOR FRACTURES- 6 TH : SCAPULA FROM TOP TO BOTTOM FOR FRACTURES- 7 TH : CHECK RIBS TWO AT A TIME AND THE SPACE IN BETWEEN- 8 TH SCAN THE LUNGS, BUT DO NOT MAKE LUNG PATHOLOGY FROM ASHOULDER FILM . BUT RECOMMEND CHEST FILMS, OR REFERRAL- TAKE FILMS WITH AND WITHOUT WEIGHTS FOR MOVEMENT OF THE ACJOINT . POSSIBLE SEPARATION- TWO SIGNS THAT SHOW A CHRONIC SHOULDER DISLOCATION:o HATCHET DEFORMITY = HILLSACK ’SS FRACTURE OF THE HEAD OF THE HUMOROUSo BANKART LESION = EROSION OF THE GLENOHUMERAL FOSSAo ORTHOPEDIC TESTS:O DUGAS TESTD APPREHENSION TEST- H.A.D.D = HYDROXY APPETITE DEPOSITION DZo CALCIUM CRYSTALS IN THE SHOULDER- DDX: USING CLOCKo CALCIFIC BURSITISo SUB-DELTOID BURSA (3,9)o SUB-ACROMIAL BURSA (12) - o CALCIFIC TENDONITISo SUPRA-SPINATUS TENDON (2,10)ELBOW:- FRACTURES, ARTHRITIS OR FAT PADS- GROWTH CENTERS IN CHILDREN- FAT PAD SIGNS: ANTERIOR AND POSTERIORo INDICATE INFLAMMATIONo TRAUMA, INFECTION OR INFLAMMATORY ARTHRITIST ANTERIOR FAT PAD: DARKER THEN SOFT TISSUEA CAN BE NORMALLY SEENC PARALLEL - RIGHT UP AGAINST THE BONE IFNORMALNABNORMAL . PUSHED AWAY FROM THE BONE
  35. 35. PART IV BOARD REVIEW 35P “SAIL SIGN ”” POSTERIOR FAT PAD: DARKER THEN SOFT TISSUEP NEVER NORMALLY SEENN ALWAYS MEANS INFLAMMATIONA NOT PARALLELN RHEUMATOID ARTHRITIS- FRACTURE OF THE ELBOW:o AREA OF OVER PENETRATION OF THE ULNAA NORMALo TRAUMATIC FRACTURE OF THE PROXIMAL ULNA = NIGHT STICKFRACTUREFNIGHT STICK FRACTURE AND DISLOCATION OF THERADIAL HEAD = MONTEGGE FRACTUREo FRACTURE OF THE DISTAL 1/3 OF THE RADIUS WITHDISLOCATION OF THE ULNA AT THE WRIST = GALAZZEFRACTUREo FRACTURE OF THE RADIAL HEAD = VERTICAL RADIOLUCENCYF CHISEL FRACTUREo LATERAL ELBOW VIEW:L LIPPING AND SPURRING OF THE JOINTL INFLAMMATIONI SUBCHONDRAL SCLEROSIS = DJDWRIST AND HAND:- INSPECT FILM PROXIMAL TO DISTAL ANATOMICALLY- PERIOSTEAL REACTION . BUCKLING OF THE CORTEX- CHECK CORTEX FOR DISCONTINUANCE- CHECK COLOR AND SHAPE - - BONE DISPLACED FROM IT-SELF = FXIN CHILD = GREEN STICK FRACTURE = HICKORY STICK FX- IMPACTION OF THE LONG BONE = TORUS FRACTUREo OR BUCKLING FRACTURE- COLLES FRACTURE IS A FRACTURE OF THE DISTAL RADIUS IN WHICHTHE MOST DISTAL PORTION OF THE RADIUS GOES POSTERIOR TO THESHAFT IN ANATOMICAL POSITION- IF THE MOST DISTAL PORTION GOES ANTERIOR TO THE SHAFT IT ISCALLED SMITH ’S FRACTURE- MORE LIKELY TO GET A COLLES FX THEN A SMITH ’S FX- ON TEST***SILVER FORK OR DINNER FORK DEFORMITY = COLLES FX- IF THERE IS A FRACTURED ULNAR IT DOES NOT EXPLAIN THE
  36. 36. PART IV BOARD REVIEW 36FRACTURED RADIUS-LATERAL WRIST VIEW: TAKEN FOR THREE BONESo THUMB IS ANTERIOR TO THE HAND FOR POSITIONINGo RADIUS = ANGLED AWAY FROM THUMB = COLLES FXC ANGLED TOWARD THE THUMB = SMITHS FX OR REVERSECOLLES FXo ULNA:U 25% OF SLIPPAGE ANT/POST TO THE THUMB =DISLOCATIONo LUNATE:L 25% OF SLIPPAGE ANT/POST TO THE THUMB =DISLOCATIONo CARPAL BONES:o RADIUS = CONCAVE SHAPEo ULNA =1. SCAPHOID:1 FRACTUREDF WILL SEE A BREAK ACROSS THE MIDDLEW DISLOCATED:D SIGNET RING SIGN – CIRCLE OF WHITEC TERRY THOMAS SIGN . BIG SPACE BETWEENSCAPHOID AND LUNATES AVASCULAR NECROSISA TURNS WHITER ’’ PRIESSER ’S DZ2. LUNATE:2 FRACTUREF DISLOCATED = BECOMES TRIANGULAR IN SHAPEB PIE SIGN SLICE OF PIE APPEARANCEP ALTERATION OF THE JOINT SPACESA AVASCULAR NECROSISA KEINBOCK ’S DZS FRACTURE WITH AVASCULAR NECROSIS =CRESCENT SIGN - - MOTTLED BONE APPEARANCE
  37. 37. PART IV BOARD REVIEW 37- RARELY ASKED ARE:3. TRIQUETRUM4. PISIFORM5. TRAPEZIUM6. TRAPEZOID7. CAPITATES8. HAMATE9. HOOK OF THE HAMATEOBLIQUES VIEW:- MOTIVE = TAKEN FOR FRACTURE OF METACARPALSDEVIATION VIEW:- MOTIVE = TWO BONES ONLY- SCAPHOID AND LUNATEA-P HAND:- MCP ’S = RA- DIP ’S = OSTEOARTHRITIS OR PSORIATIC ARTHRITISo WHITE . OAo DARK = PA- PSORIATIC ARTHRITIS:o RESORPTION OF THE DISTAL TUFTSo ALSO CAUSED BY SCLERODERMA, DOES NOT INVOLVE JOINTSPACESo ASSOCIATED WITH CREST SYNDROME :A CALCINOSISC RAYNAUD ’S PHENOMENAS ESOPHAGEAL PROBLEMSE SCLERODACTALYS TELANGECTASISo AUTOACROLYSIS = RESORPTION OF THE DISTAL TUFTSo EARLY STAGE PSORIATIC = MOUSE EAR DEFORMITYM PERI-ARTICULAR EROSIONSo LATE STAGE PSORIATIC = PENCIL AND CUP DEFORMITYo WITH SKIN LESIONS AND JOINT PAINo RAY SIGN = USE ONLY AFTER DX IS MAGE= INFLAMMATORY DISTRUCTION IN THE MCP, PIP ANDDIP- PHALANGESo FOR DEVIATION- PIP ’S = DECREASED AND WHITER ’o OSTEOARTHRITIS= DECREASED AND WHITERS RAT BITE EROSIONS
  38. 38. PART IV BOARD REVIEW 38o PSORIATIC ARTHRITIS = DECREASED AND DARKERo GOUT = JUXTA-ARTICULAR EROSIONS= NO DISTRIBUTION PROBLEMN OVERHANGING EDGE SIGN - - DISTRUCTION ABOVE AND BELOW THE JOINTPNEUMONIC FOR MCP FRACTURES:- BE = BENNETT ’S FRACTURE = 1 ST MCPo MORE THEN TWO PIECES = ROLANDO FX- BO = 2 ND OR 3 RD MCP = BOXER ’S FX- BA = 4 TH OR 5 TH MCP = BAR ROOM FXBENIGN VS MALIGNANT NEOPLASM ’S OF THE BONE:BENIGN NEOPLASM ’S:1. UNICAMERAL BONE CYST OR SIMPLE BONECYSTa. UNDER THE AGE OF 20b. LOCATION . METAPHYSEAL, DIAPHYSEAL,CENTRALLY LOCATED (ONE SIDE ORCORTEX TO THE OTHER)c. ASSOCIATED WITH “FALLEN FRAGMENTSIGN ”d. FLUID FILLED TUMOR . RAISE ARM ANDRE-X-RAY THE BONE FRAGMENTS FLOATTO BOTTOM2. ANEURISMAL BONE CYSTa. AGE UNDER THE AGE OF 20b. LOCATION . METAPHYSEAL, DIAPHYSEAL,ECCENTRICALLY LOCATED (OFF TO ONESIDE OF THE SHAFT)c. BLISTER OF BONE APPEARANCEd. DO NOT BIOPSY . RUPTUREe. WALLED OFF ON THE INSIDE3. GIANT CELL TUMORa. OSTEOCLASTOMAb. OVER THE AGE OF 20c. LOCATION . METAPHYSEAL EPIPHYSEAL,d.e. ENCAPSULATEDf. QUASI-MALIGNANT = CAN BECOME ASARCOMA (SARCOMA HAS PERIOSTEALREACTION)g. NO EXPANSION IN MM OR METSh. SOAP BUBBLE APPEARANCEi. GEODE OR SUBCHONDRAL CYST4. CHONDROBLASTOMA
  39. 39. PART IV BOARD REVIEW 39a. UNDER AGE 20 - b. LOCATION- EPIPHYSEAL, METAPHYSEALON TEST: IF YOU SEE BONE EXPANSION WITH THE CORTEX INTACT- PUTTHREE BENIGNTUMORSREFER OUT TO ORTHOPEDISTENCAPSULATEDSHORT ZONE OF TRANSITION . SURROUNDED BY NORMAL BONEONE LOCAL GEOGRAPHIC LESIONMOST COMMON BENIGN TUMOR OF THE AXIAL SKELETON =OSTEOCHONDROMATWO TYPES:- PEDUNCULATED = ON A STALKo CARTILAGINOUS CAPo CAULIFLOWER SHAPE APPEARANCEo NOT WALLED OFF ON THE INSIDE- SESSILE = RAISED ROUNDED AREAo BROAD BASED EXOSTOSISo CAN BE CONFUSED WITH ANEURISMAL BONE CYSTEXCEPT- POLYOSTOTIC FORM OF FIBROUS DYSPLASIA- HEREDITARY MULTIPLE EXOSTOSIS = MULTIPLE OSTEOCHONDROMA ’S- OLLIER ’S DZ . MULTIPLE ENCHONDROMA ’SASYMPTOMATIC = PAINLESSEXCEPT OSTEOID OSTEOMA = PAIN WORSE AT NIGHT RELIEVED BYASPIRINNO LAB TESTS FOR BENIGN TUMORSSPECIAL TESTS: CT, BONE SCAN, MRI OR BIOPSYONE YOU DO NOT BIOPSY = ANEURISMAL BONE TUMORMALIGNANT TUMOR: LYTIC METS OR MULTIPLE MYELOMANOT ENCAPSULATEDLONG ZONE OF TRANSITIONUSUALLY MULTIPLE LESIONSPAINFULLAB TESTS:- REVERSE A/G RATIO- IMMUNOPHORESIS- M SPIKE OF IgG- BENCE JONES PROTEINURIA- METS= ALKALINE PHOSPHATASESPECIAL TESTS SAME AS BENIGN TUMORSREFERRAL TO ONCOLOGISTS OR ORTHOPEDISTSHOW DO YOU KNOW IT IS NOT GAS????USE A 30° TILT UP VIEW WITH ANIMAL EARS
  40. 40. PART IV BOARD REVIEW 40 - GAS IS BLACK, ENCAPSULATED USUALLY AND CAN BE SEEN IN DIFFERENT POSITIONSMOST COMMON BENIGN TUMOR OF THE SPINE:HEMANGIOMA = CORDUROY CLOTH APPEARANCE, JAIL BAR VERTEBRA,VERTICALSTRIATIONSNEVER MORE THEN TWO VERTEBRA = OSTEOPOROSISON A-P FILM . THE HEMANGIOMA APPEARS HONEY COMB, MAKESPEDICLES APPEAR LIKETHEY HAVE BEEN EATON AWAYSO IF YOU SEE THE HEMANGIOMA ON THE LATERAL “DON ’T PICK LYTICMETS ”!!!!!HAND: “ALL RULES ARE OUT ”1. BENIGN TUMOR IN THE HAND PUT ENCHONDROMA ’Sa. SPECKLED CALCIFICATION WITHIN TUMOR2. MORE THEN ONE ENCHONDROMA ’S = OLLIER ’S DZ3. TINY WHITE SPOTS WITHIN THE BONE = MULTIPLE BONE ISLANDS OROSTEOPOIKYLOSIS (ENOSTOMA)4. PAIN WORSE AT NIGHT RELIEVED BY ASPIRIN . OSTEOID OSTEOMAa. RADIOLUCENT CENTRAL NIDUS (1CM), SURROUNDED BY SEVEREREACTIVESCLEROSISb. DDX . BRODIES ABSCESS = CHRONIC OSTEOMYELITIS (>2 CM WITHMILDERSCLEROSIS)5. BONE INFARCT = AVASCULAR NECROSIS TO THE METAPHYSIS OF THEBONEa. TURNS WHITER ’b. WHITE CHEWED UP PIECE OF CHEWING GUM SIGN (DONOFRIO ’S)c. MOST COMMONLY ASSOCIATED WITH CAISSON ’S DZ (THE BENDS) ORDIABETESMELLITUS6. TWO BENIGN FIBROUS TUMORS CHANGED NAMES BY AGE:a. FIBROUS CORTICAL DEFECT . UNDER AGE 8b. NON-OSSIFYING FIBROMA . OVER THE AGE OF 9i. LEAVE THEM ALONE7. RIND SIGN = THICK ENCAPSULATION OF MONOSTOTIC FIBROUSDYSPLASIAa. ASSOCIATED WITH CAFÉ ’ A LAIT SPOTS8. SKULL:a. OSTEOMA = MOST COMMON BENIGN TUMOR OF THE SKULLb. FOUND IN THE FRONTAL SINUSc. WATER ’S VIEW . FOR FRONTAL SINUS - 9. WHITE POPCORN APPEARANCE WITHIN A JOINT . SYNOVIAL CHONDROMETAPLASIA
  41. 41. PART IV BOARD REVIEW 41REVIEW CHEST FILMS TO COMPLETE X-RAY REVIEWCOMPENSATORY EMPHYSEMATUBERCULOSIS CONTRACTION - CONGESTIVE HEART FAILURE

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