Radiographic Imaging Cervical Spine Imaging Standard Cervical
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5/2/14 Radiographic Imaging Benefits Visualization of significant osseous and articular pathology Risks No safe amount of ionizing radiation Limitations Articular cartilage Soft tissues Hector RiveraMelo DC, DACBR hectormelo@scuhs.edu Cervical Spine Imaging Standard Early osseous and articular changes Standard Cervical Spine Series AP Lower Cervical Lateral radiographic series AP lower cervical AP open mouth Lateral Standard Cervical Spine Series AP Open Mouth Cervical Spine Imaging Accessory radiographic views Obliques Flexion/Extension 1 5/2/14 Accessory Cervical Spine Views Accessory Cervical Spine Views Anterior Obliques Extension Flexion Cervical Spine Imaging Cervical Spine Imaging Common Common pathology seen on X-rays Osteoarthritis ○ Degenerative disc disease ○ Facet arthrosis ○ Uncovertebral arthrosis pathology not seen on X-rays Disc herniations Chiari malformations Facet fractures* DISH Congenital annomalies Hangman’s fracture (C2) Unilateral facet dislocation C1/2 Mach Effect • Gives the appearance of a lucent line. • An optical phenomenon from edge enhancement due to lateral inhibition in the retina. • Occurs when two objects of similar but different densities overlap. 2 5/2/14 C1/2 Odontoid Fracture Question about C2/3… Congenital Block Vertebrae C2/3 • The facets at C2/3 are at a slightly different angle than the rest of the lower cervical spine facets. • C2/3 is a common location. • Often accompanied by occipitalization of C1. • “Pseudofusion” appearance is very common. • “Wasp-waist” appearance anteriorly. • Posterior element involvement • Lack of body involvement is a big clue. Facet Arthrosis Nuchal Bones and C1 Accessory Ossicle with intercalary bones • Radiographic Features: • Hypertrophy (enlargement) of the articular processes • Sclerosis • Anterior or posterior translations (advanced) • Nuchal Bones • Ossicles within the nuchal ligament. • Seen more commonly with increased age. • Considered a normal variant. • DDx: SP fracture 3 5/2/14 Nuchal Bones and C1 Accessory Ossicle Nuchal Bones and C1 Accessory Ossicle with intercalary bones with intercalary bones • Intercalary Bones • C1 Accessory Ossicle • Degenerative calcification of the anterior fibers of the intervertebral disc. • Accessory ossicle of no clinical significance. • DDx: • Considered a normal variant. • Calcification of the ALL (DISH). • DDx: • Atherosclerosis of the carotid arteries. • HADD of the longus colli • Tear-Drop fracture. • ALL calcification Old SP fracture of T1 66 yoM with C/S pain • AKA: Clay-shoveler’s fracture • Inferior displacement of fragment • Parent/Donor site • A stable injury • DDx: • Ununited growth center. Carotid Artery Atherosclerosis Jefferson Fracture • This is a common location for atherosclerosis. • Will often look less tube-like and more globular. • Will often see accompanying atherosclerosis of other large arteries. Bonus: Tear-Drop Fracture 4 5/2/14 Jefferson Fracture Tear-Drop Fracture • Burst fracture of C1. Two mechanisms: • Mechanism of injury usually axial loading. • Extension: • A stable injury • The result of an avulsion of anterior body by ALL. • Flexion: • A highly unstable injury • The result of compressive forces, often with extensive damage to the posterior elements. • Classically see overhanging lateral masses of C1. • Frequently accompanied by other C/S injuries. What’s Wrong Here? Normal Pediatric C/S • Vertebral bodies are oddly shaped. • Disc heights and joint spaces appear larger. • Endplates appear to be separated. Right Sided Aortic Arch • This is an uncommon congenital anomaly. (0.1% of the population) • May be associated with other more serious congenital heart diseases. Thoracic Spine Imaging Standard radiographic series AP Lateral • Of course, it’s possible that the technician simply placed the marker on the wrong side… 5 5/2/14 Standard Thoracic Spine Series AP Lateral Thoracic Spine Imaging Accessory radiographic views PA Chest Accessory Thoracic Spine Views PA Chest Thoracic Spine Imaging Common pathology seen on X-rays Osteoarthritis ○ Degenerative disc disease ○ Facet arthrosis ○ Costotransverse arthrosis Scoliosis Compression fractures Rib fractures Thoracic Spine Imaging Common Ununited TP Of T1 pathology not seen on X-rays Early Infection Early osteoporosis Asthma T1 • Smooth/round borders • Upper thoracic spine is a very common location. • This is a very uncommon location for fractures. • DDx: • TP fracture • Rib fracture • HADD of the scalenes 6 5/2/14 20 yof with c/s and t/s pain Hair Artifacts What happened here? What went wrong? • This is an unaltered (not cropped) image taken at a chiropractic office. • Multiple metallic curvilinear densities. • Seen outside the chest. • Intended to be a lateral thoracic spine view. • Here’s another patient with the same mystery… • What went wrong? • Cassette not pushed in all the way. • Acupuncture needles!! QUIZ Lumbar Spine Imaging 1) Which of the following 2) Which of the following levels o6en gives the is considered a sign of false appearance of pathology? facet fusion? a) b) c) d) C1/2 C2/3 C3/4 C5/6 a) b) c) d) • Even digital machines use cassettes (CR) Standard radiographic series AP (or PA) Lateral Nuchal bones Intercalary bones Mach bands Ununited growth centers 7 5/2/14 Standard Lumbar Spine Series Lateral AP Lumbar Spine Imaging Accessory radiographic views AP (or PA) L5/S1 spot Lateral L5/S1 spot Obliques Flexion/Extension Accessory Lumbar Spine Views Accessory Lumbar Spine Views Anterior or Posterior Obliques Flexion Extension R Accessory Lumbar Spine Views Lateral L5/S1 Spot Lumbar Spine Imaging AP L5/S1 Spot Common pathology seen on X-rays Osteoarthritis ○ Degenerative disc disease ○ Facet arthrosis Ankylosing Spondylitis Compression fractures DISH Atherosclerosis of the Abdominal Aorta Congenital anomalies 8 5/2/14 16yoF with lbp Lumbar Spine Imaging Common pathology not seen on X-rays Disc herniations Sciatica Piriformis Syndrome 16yoF with lbp Normal Transverse Processes 50yoF with lbp Metastatic Breast Cancer (Blastic) • Ivory Vertebra • DDx: • Blastic Metastasis • Lymphoma • Pagets Disease • Notice the osseous destruction of the TP. 9 5/2/14 56yom with lbp 48yom with lbp Limbus Bones 38yof with lbp • Very common in the lumbar spine. • Represent intravertebral disc herniations. • Typically asymptomatic (especially if anterior). R Gall Stones 39yom with lbp following MVA • Located in the right upper quadrant. • Tend to be more dense around the periphery. • Common in females over 40. • May or may not be symptomatic. 10 5/2/14 Hydroxyapatite deposition disease Transitional Segment • Aka: Calcific tendinitis • Commonly seen at the lumbosacral junction. • Cloud-like calcification • 7 Subtypes: • Most common locations: • Shoulder • Hip • Wrist 35yom with lbp following MVA Swallowed Piercing • Patient reported swallowing a piercing during car accident • Doctor did not specify what kind of piercing. 29yom with lbp Ankylosing Spondylitis • Common in young males. • May just present with low back stiffness. • Vertebral body squaring and erosions. • SI joint fusion occurs in at least 50% of patients. • Bilateral symmetry is classic. 11 5/2/14 Extremity Imaging Common indications for extremity imaging Unresponsive to care after 4 weeks Significant activity restriction >4 weeks Non-mechanical pain Upper extremity Osteoarthritis unrelieved by conservative care Suspected/known inflammatory arthritis Significant trauma Suspected physical abuse in children Hector RiveraMelo, DC, DACBR hectormelo@scuhs.edu Extremity Imaging Shoulder Imaging Red Standard flag indicators radiographic series Signs/symptoms or history of cancer AP internal rotation Red skin, fever, immunosuppressed AP external rotation History of non-investigated trauma Baby arm Unexplained significant sensory/motor deficit Standard Shoulder Series AP Internal Rotation AP External Rotation Standard Shoulder Series Baby Arm 12 5/2/14 Shoulder Imaging Accessory Accessory Shoulder Views Axial radiographic views Axial Trans-scapular ‘Y’ Accessory Shoulder Views Trans-scapular ‘Y’ Shoulder Imaging Common pathology seen on X-rays Hydroxyapatite Deposition Disease (HADD) AC injuries (grades II-III) Glenohumeral dislocations Osteoarthritis (especially AC) Clavicular fractures Shoulder Imaging Common 44 Year-old M pathology not seen on X-rays Rotator cuff injury Adhesive capsulitis Impingement syndrome Labral injury AC injury (grade I) 13 5/2/14 44 Year-old M 44 Year-old M Absent 4th Rib on the left 79yoM: Acute shoulder pain • Examine the whole film: • Don’t forget the ribs on shoulder views. • Potential causes include: • Post-surgical • Aggressive tumor Clavicle fx with multiple rib fxs QUIZ • Ribs 2 and 3 involved • No pneumothorax • Significant Osteoporosis 1) Which of the following 2) Which of the following is a common is a standard view of pathology seen on the thoracic spine? lumbar spine x-­‐rays? a) b) c) d) Disc herniaLons Atherosclerosis SciaLca Piriformis Syndrome a) b) c) d) AP thoracic PA thoracic AP chest PA chest 14 5/2/14 Standard Wrist Series Wrist Imaging Standard PA Lateral radiographic series PA Lateral Medial oblique PA ulnar deviation Standard Wrist Series Medial Oblique PA Ulnar Deviation Wrist Imaging Accessory radiographic views Carpal Tunnel Angulated Scaphoid Accessory Wrist Views Carpal Tunnel Wrist Imaging Angulated Scaphoid Common pathology seen on X-rays Osteoarthritis (especially 1st CMC joint) Scaphoid fractures Distal radial fractures Instability Lunate dislocations Inflammatory arthritis Avascular necrosis 15 5/2/14 Wrist Imaging Hand Imaging Common Standard pathology not seen on X-rays radiographic series Nerve entrapment syndromes PA Ganglion cysts Lateral Sprain/Strain Medial oblique Standard Hand Series Lateral PA Hand Imaging Medial Oblique Common pathology seen on X-rays Osteoarthritis (especially DIPs) Metacarpal fractures (especially 4th & 5th) Interphalangeal fractures/dislocations Avulsion injuries Inflammatory arthritis (especially MCPs) Benign Enchondromas Penetrating injuries Hand Imaging Common 38yof w/ trauma and thumb pain pathology not seen on X-rays Nerve entrapment syndromes 16 5/2/14 Enchondroma with path fracture • Benign cartilagenous lesion with very low rate of malignant degeneration. • Represents the most common benign tumor of the hand. Lower extremity • Typically asymptomatic until fracture occurs. • Occasionally found incidentally. Hector RiveraMelo DC, DACBR hector.dacbr@gmail.com Standard Hip Series Hip Imaging Standard AP Pelvis radiographic series AP Pelvis AP Spot Frog Leg Standard Hip Series AP Spot Frog Leg Hip Imaging Accessory radiographic views Judet Long bone study of the femur 17 5/2/14 Accessory Hip Views Judet Hip Imaging Long bone study Common pathology seen on X-rays Osteoarthritis Avascular necrosis Hydroxyapatite Deposition Disease (HADD) Developmental dysplasia of the hip Femoral-acetabular impingement syndrome Femoral neck fractures Inflammatory arthritis 65 yom 1 year post-surgery follow up Hip Imaging Common pathology not seen on X-rays Sciatic or other nerve impingement syndromes (piriformis syndrome) Labral injuries Bursiits Muscle tears 65 yom 1 year post-surgery follow up Pre-Op Nutrient Canal • Seen commonly in long bones. • From the knee we flee! • To the elbow we go! • Typically will not see medullary involvement • Smooth with no cortical offset. Post-Op 18 5/2/14 20of w/ hip pain Simple Bone Cyst • AKA: Unicameral Bone Cyst • Benign cystic lesion with no malignant degeneration. • Common in long bones (humerus=MC location) • Typically asymptomatic until fracture occurs. • Occasionally found incidentally. QUIZ Knee Imaging 1) Which is the most 2) Which of the following common benign tumor is a standard view of of the hand? the hip? a) b) c) d) Osteoid Osteoma Osteochondroma Enchondroma Metastasis a) b) c) d) radiographic series AP Lateral Frog-­‐leg Lateral pelvis Lateral spot hip Judet Standard Knee Series AP Standard Lateral Knee Imaging Accessory radiographic views Oblique Tangential (Sunrise) Intercondylar (Tunnel) Long bone studies 19 5/2/14 Knee Accessory Views Knee Accessory Views Medial Oblique Long bone study Intercondylar (Tunnel) Tangential (Sunrise) Knee Imaging: Ottawa Knee Rules Catch high percentage of fractures of the knee Order x-rays of the knee if there is trauma to the knee and any of the following: ○ Age ≥55 ○ Isolated tenderness at: Head of the fibula Patella ○ Inability to flex knee >90° Knee Imaging Common pathology seen on X-rays Osteoarthritis Osteochondral defects (femur) Calcium pyrophosphate deposition disease (CPPD) Proximal fibular/tibial fractures Aggressive and benign 1°bone tumors ○ Inability to walk 4 weight- bearing steps at presentation or at presentation Knee Imaging Common 59 yof with bilateral knee pain pathology not seen on X-rays Patellar tendinitis (Jumpers knee) Meniscal injury ACL, PCL, MCL, LCL injury Sprain/Strain Chondromalacia Patella Osgood-Schlatter disease* 20 5/2/14 49 yof with bilateral knee pain Osteoarthritis of the knees • Age range is typically <45 • Typically asymmetric involvement. • Prominent osteophytes • Medial joint compartment typically affected 1st. 31 yom with right knee pain Fabella • A sesamoid bone. • Located within the tendon of the lateral head of the gastrocnemious muscle. • A very common normal variant. 41 yof with right knee pain Cyamella • A sesamoid bone, similar to the fabella. • Located within the tendon of the popliteus muscle. • A normal variant 21 5/2/14 Meniscal Ossicle • An accessory ossicle. • Located within the meniscus. • Typically seen posteriorly and medially • May be triangular. • An uncommon normal variant. 66 yoM with left knee pain Popliteal Artery Atherosclerosis • This is a common location for atherosclerosis. • The popliteal artery is the most common location for peripheral aneurysms. • Will often see accompanying atherosclerosis of other large arteries. 44 yom with bilateral knee pain 44 yom with bilateral knee pain 22 5/2/14 35 yom with right knee pain Synovial Osteochondromatosis • AKA: Synovial Chondrometaplasia, Synovial Chondromatosis • Caused by flaking off of synovial lining. • The knee is the most commonly affected joint • May be 1’ • or 2’ to osteoarthritis • 2:1 Male:Female ratio 12yom with right leg pain Infrapatellar Fat Pad Syndrome • AKA: Hoffa’s Disease • Rare cause of knee pain • Caused by injury (acute or chronic) to the fat pad. • May be pinched with full extension • Seen in jumping and kneeling athletes. • DDx for anterior knee pain: • Patellar tendonitis • Synovial chondromatosis • Ganglion Cysts • Chondromalacia Patella 12yom with right leg pain Lymphoma • Abnormal periosteal reaction of tibia • DDx. • Osteosarcoma • Ewing’s Sarcoma • Osteomyelitis • Lymphoma • Leukemia 23 5/2/14 More Acupuncture Needles!! Foot Imaging Standard radiographic series DP Lateral Medial oblique Standard Foot Series DP Medial Oblique Foot Imaging Accessory Standard Foot Series Lateral Accessory Foot Views Tangential Calcaneus (Harris-Beath) radiographic views Tangential Calcaneus (Harris-Beath) 24 5/2/14 Foot Imaging Foot Imaging Common Common pathology seen on X-rays pathology not typically seen on Osteoarthritis (especially 1st MTP) X-rays Phalangeal fractures (especially 4th & 5th) Plantar fasciitis Interphalangeal fractures/dislocations Mortons neuroma Avulsion injuries Inflammatory arthritis (especially MCPs) 38 yom with foot pain Os Peroneum And Os Intermetatarseum • Os Peroneum • A sesamoid bone within the peroneus longus tendon. • Os Intermetatarseum • An accessory ossicle which may form a synovial joint with the first or second metatarsal or medial cuneiform. 22 yom with foot pain Os Vesalianum • Ossicle, representing an ununited secondary growth center at the styloid of the 5th metatarsal. 25 5/2/14 27 yof with foot pain 5th Metatarsal Fracture • Avulsion fracture of the 5th metatarsal styloid. • Occurs at the insertion of the Peroneus brevis tendon. • Relatively common among tennis players • Generally respond well to conservative treatment (casting) QUIZ How to have your films read: 1) Which of the following 2) Which of the following is a pathologic finding is an accessory view of in the knee? the knee? a) b) c) d) Fabella Cyamella Meniscal Ossicle Atherosclerosis a) b) c) d) Intercondylar AP Lateral Femoral Head SCU http://www.scuhealth.org/DI hectormelo@scuhs.edu We’re also on facebook! www.facebook.com/SCUdiagnosticimaging 26
