X-ray Diagnosis Tri 6
1
TERMS:
Osteopenia – reduced bone mass; decreased bone density.
Radiolucent – clear to X-ray photography (appears black).
Radiopaque – X-ray dense or absorbed (appears white from X-ray absorption).
Cortical bone, trabecular bone, muscle, water, air, fat
Contrast (image) – differentiation, generally in black and white. High contrast = reduced
grayscale.
Differential absorption – different absorption properties of different materials based on atomic
properties.
Contrast (i.e. oral, bronchogram, angiography [arteriograms and venograms], arthrogram,
air-sinogram) – foreign substance introduced to the body that yields high contrast radiography.
Metastasis – beyond stasis; malignant cancer or infection.
DESCRIBE TYPES OF BONE DEVELOPMENT:
Intramembranous and enchondral.
Intramembranous – primarily flat bones (facial, calvaria, ilia). Periosteal tissue maintains bone
via periosteum and endosteum. Bone repair following fracture ensues via this method.
Enchondral – classic manner of long bone formation; formed in chondral tissue.
Hematopoietic sites in a:
Child: bones (all). Necessary for growth and development.
Adult: ends of the longs bones (metastasis) and flat bone (pelvis, sternum, ribs, and spine).
Geriatric: Reduced to smaller areas of the metastases and spine, ribs, ilium)
Draw a femur and label the parts:
Greater trochanter
Lesser trochanter
Shaft
Neck
Head
Fovia capitis
Medial condyle
Lateral condyle
Medial epicondyle
Lateral epicondyle
Linea aspira
Nutrient foramen
Growth plates
Intertrochanteric line
Epiphysis
Metaphysis
Periosteum
Cortex
Why do we use X-ray?
Proper use of X-ray is for attempting to document the differential or confirm a diagnosis:
Trauma
Mammography or other familial disease
Review of systems
When do we use radiology?
General procedure for a patient:
Paperwork
X-ray Diagnosis Tri 6
2
Interview and consultation
History (LOPPQqRSTTxB)
Inspection and PE
Palpation
Percussion
Instrumentation
ROM
Orthopedic
Neurologic
Document clinical findings and derive a differential diagnosis
Appropriate time for report of findings, or release the patient, or accept the person as a patient
with contractual obligations.
E X-ray
Lab
There are exceptions to following the above protocol.
Documentation:
Liability:
GP read all films – held as specialist in X-ray in court.
GP reads some films and sends others - held as specialist in X-ray in court.
GP sends all – GP liability only.
Basically, this translates to only two levels of liability.
Chiropractic radiologists
71.00
Skeletal radiologists and fellows
Chiropractic radiology residents
General medical radiologists
Medical radiology residents
Medical clinicians
Chiropractic clinicians
Chiropractic students
Medical students
70.18
61.54
51.64
44.64
31.26
28.38
20.45
05.
Rule in, rule out, or monitor a know condition all with proper documentation is purpose for
taking X-ray.
It is easy to sue for low initial court filing costs. Some recommend that you not let a patient’s
bill get over $200. Much of what we learn has design to protect against legal suits. Often it is
more profitable to outsource as much as possible to reduce liability.
HOW DO WE COMMUNICATE THE RESULTS:
The X-ray report has design to verbally communicate the X-ray status.
Useful to communicate between doctors and offices.
X-ray Diagnosis Tri 6
To allow investigation by other specialists.
X-ray report is satisfactory replacement of X-ray film.
Attorneys need reports to make a case.
Workers Comp and Insurance have reviews for reimbursement.
The patient pays for the information derived from the X-ray but not the X-ray itself. Additionally, the doctor has
legal obligation to maintain the X-ray records.
INFORMATION ON AN X-ray REPORT:
I.
Imaging center (who is interpreting the report).
II.
Patient information (who, age, DOB).
III.
Radiographic information (date of exam, series, technique [mA x time x kVp] optional normally in a logbook).
IV.
Body of report: generic, descriptive, in the fewest words possible (with use of
“buzzwords”).
V.
Impressions: interpretation noted (differential diagnosis from most important to least
important).
VI.
Recommendation/comment (optional) – Dr. Kuhn says to rarely use this part.
IMAGING TOOLS AVAILABLE
Know about the study, cost, and what it will do or not do.
Have the ability to communicate the method to a patient.
Imaging tools







Plain film
Myelography
Computerized tomography
Helical Computerized tomography
MRI
Bone scan
SPECT
Plain film – Wilhelm Conrad Roentgen (11/8/1895)
Strengths: availability, relatively low cost, well known usage.
Weaknesses: ionizing radiation, relatively poor resolution, poor spatial localization, soft tissues
generally not seen.
Proper use: introductory study, can evaluate IVF well, use to rule out contraindications for advanced imaging, not
good for central canal stenosis.
Conventional tomography – largely replaced by CT.
1. Linear.
2. Circular.
3. Elliptical.
4. Hypocycloidal.
5. Trispiral.
Myelography
Production: utilizes ionizing radiation, depends on displacement of contrast column, differential absorption.
- air was the first contrast agent used. Other materials include poppy seed oil, pantopaque. In the 1940’s water
soluble products (very toxic). 1970 metrizamide non-ionic, water soluble, in use today.
3
X-ray Diagnosis Tri 6
4
Complications: arachnoiditis, infections, arterial bleeding, headache is the most common complication.
Proper use:
Disc herniation – sharp angular indentation on the thecal sac, decreased IVD, enlargement of a nerve root sleeve
secondary to edema, displacement of non-filling of a root sleeve.
If CT or MR are not available
Patient who cannot undergo MRI because of time, size, claustrophobia, other contra-indications
May be used in conjunction with CT.
Weakness: more expensive than MRI, ionizing radiation, relatively poor resolution, soft tissues not well seen, high
rate of false negatives, potential complications from contrast agent.
Strengths: relatively good availability, good cost benefit ratio, well known utilization.
Computerized Tomography:
Technical aspects: ionizing radiation, absorption differentials, computer generated pictures, Hounsfield unit, pixels,
voxels, volume averaging, slice thickness scout films. Best thing it does is axial imaging.
Strengths: widely available, improved visualization of soft tissues, can provide three dimensional imaging,
accurately measure a variety of structures, image manipulation possible. Only 1-3 percent change in bone
density will show up on CT. Allows for a change in parameters to view different level(s) and window(s).
Weaknesses: higher cost than plain film and lower than cost MRI, ionizing radiation, intracranial artifacts, artifacts
secondary to metallic implants, dose is a consideration.
Proper use: very good axial images, excellent bone detail, some application in the neurology work-up.
Vacuum phenomena – air trapped in what was nucleus pulposis.
Vacuum cleft – air trapped in what was the annulus fibrosis.
Helical computerized tomography:
CT donut spins and patient continually moves through the scanner.
Throughput time and image quality improved.
Produces a higher density of data.
MRI:
Technical aspects:
- MRI technologies developed from nuclear resonance used to evaluate chemical composition of laboratory
samples.
- Raymond Damadin first produced a full body MRI in 1976.
Equipment:
- gantry contains one of three types of magnets.
1. super conducting magnet – primary magnetic coils super cooled
2. permanent magnets – open magnetic resonance utilizes this type of magnetic reducing claustrophobic
affects. Cannot achieve the high field strength of super conducting magnet. High noise to signal ratio.
Improved software improved these images.
3. Resistive electromagnets – classic electromagnet, low initial cost, lower in weight, very high power
consumption – may consume savings in the long run.
Functional MRI requires a BIG magnet, super-cooled.
Claustrophobia is the number one reason for failure. There are reports that the contrast material irritates this
situation.
Magnetic resonance gradient magnetic coils:
 located within the gantry
 allow “slicing” of the patient’s anatomy
 along sagittal, coronal, or axial planes
 rapid on/off switching
 produces the loud clicks and taps heard by the patient.
Radiofrequency (RF) coils:
 placed on or near the area of interest
 used to excite target tissue
 also receives information regarding hydrogen nuclei relaxation
X-ray Diagnosis Tri 6
5
Image production
 hydrogen is a charged particle representing 80% of all the atoms in the body
 hydrogen behaves like a small bar magnet
 they are randomly oriented and their charges cancel out
 the MR scanner can spatially locate hydrogen within the body
 in the strong magnetic field of the MR unit, the hydrogen molecules tend to align with (or less often against) the
field.
 The hydrogen molecules are not held static, but are induced to demonstrate precession (wobble)
 They are aligned, but they precess or spin out of phase
 A strict linear relationship exists between the frequency of precession and the MR magnetic field.
 Energy must be added to the system. RF identical to the Larmor frequency is pulsed into the patient. This is
the concept of resonance. This causes the aligned hydrogen atoms to precess in phase. The RF pulse is turned
off in the “excited” hydrogen atoms undergo “relaxation”.
Spin Echo Sequence
The appearance of the image reflects the intensity of the emitted signal. High signal intensity appears bright and
dark areas represent areas of low signal intensity.
Intensity of the signal is determined by the quantity of mobile hydrogens and two magnetic relaxation times. T1
AND T2.
Manipulating the repetition of administered RF pulses (repetition time, TR) and collection of the emitted RF signal
(echo time, TE) influences the image characteristics. Images may be described as proton density in which the image
is based on the population of hydrogen T1-weighted or T2-weighted
MR PULSING SEQUENCES
WEIGHTING
TR
PROTON
LONG
T1
SHORT
T
LONG
TE
SHORT
SHORT
LONG
T1 protocols utilized
 TR’s of 200-500 milliseconds approximately
 TE’s lasting approximately 15 milliseconds
 T2 images are very tiny consuming protocols and have long TR’s and long TE’s
 Hybrid images have been developed to take advantage of T2 type images with greater economy of time
Imaging protocol in MRI
 the parameters selected usually represent a compromise between radiologist preference, diagnostic capability
and examination time.
 Differential considerations greatly affects image sequence selection
 Extradural disease represents the most common diagnostic request.
T1-spin echo
 essential to exam the spine; exams anatomy, marrow space, sagittal gradient echo.
Intramedullary disease
MRI – CONTRAST
 non-iodinated: adverse reactions very rare
 magnetic contrast agents
 gadolinium is the most common agent
- works as a T1 shortening agent which causes tissue containing gadolinium to appear bright on T1
- very useful in cases of:
 CNS tumor
 MS
 disc herniation versus scar tissue
X-ray Diagnosis Tri 6
6
MRI STRENGTHS
 superior resolution
 superior tissue contrast
 images soft tissue very well
 non-contrast enhancement in the spinal canal
 axial images OK
 coronal, sagittal, etc. images are superior
 MRA can produce non-contrast visualization of major and minor vessels
 Measurements may be accomplished
 MR reports on the physiology as well as anatomy
 Not reliant on attenuation of ionizing radiation
 No known harmful effects
MRI WEAKNESSES
 time and money
 cannot manipulate the image
 if the MR scanner is no sequenced correctly, information may be lost or hidden
 high resolution MR bone detail is adequate and on standard MR images, bone detail is poor
MRI CONTRAINDICATIONS
 pace makers, ear implants, miscellaneous implanted electronic devices, cerebrovascular clips, machine shop
workers, claustrophobia, orthopedic implants (distorts gaussian field)
FMR – functional MR; most recent work to map brain activity or functionality.
BONE SCAN
1. Injection of a radioactive isotope (technetium)
2. Uses a gamma camera or scintilla scope to view osteoblastic activity as demonstrated by technetium uptake.
SPECT/PET SCAN (Single Photon Emission CT/Positron Emitted Tomography)
SPECT is to bone scan as CT is to plain film.
PET utilizes uptake of glucose to generate pictures.
COLOR-DUPLEX SONOGRAPHY OF THE ARTERIES
Can measure the amount of occlusion.
Basic anatomy and physiology review.
Apophysis – a bump on a bone that has/had a growth plate but no articular cartilage (greater/lesser trochanter).
Calcium and phosphorous. Calcium is in use for clotting, contraction, conduction; parathormone regulates blood
calcium level and is in a 2:1 ratio with phosphorous (Ca:P). Acid phosphatase (break-down) and alkaline
phosphatase (build-up).
Calcium: phosphorous allows Ca to complex into the bone matrix. Parathormone releases with low serum Ca; this
allows improved complexing of Ca in serum through the vitamin D loop. There are normal levels of
parathormone required. Calcitonin: (unknown where, specifically, it produces) inhibits serum level increases of
Ca. Estrogen and androgens control growth as does products of anterior pituitary (growth hormone). Short
lecture on acromegaly, dwarfism, etc. Glucocorticoids released in response to certain stresses and can lead to
bone loss.
X-ray Diagnosis Tri 6
7
MENSURATION
Sella turcica size
Basilar angle
(Martin’s,
Welcker’s,
spenobasilar )
Chamberlain’s
line – know this
enough to not
use this
McGregor’s line
Horizontal : widest diameter
Vertical: fossa floor to clinoids
Nasion – center sella turcica
Basion – center sella turcica
Average
11mm
8mm
137
Min
5mm
4mm
123
Max
16mm
12mm
152
Pituitary and extrapituitary masses
enlarge the fossa
Basilar impression and platybasia widen
the angle. Yokum uses 1 (congenital;
fusion) and 2 (acquired; Paget’s,
osteomalacia, fibrous dysplasia)
Basilar impression when odontoid more
than maximum distance above. (Paget’s,
osteomalacia, etc.)
Hard palate – opisthion
(difficult to see without high
kVp/mAs technique)
Below line
to 3mm
above
7mm
Hard palate – occiput. Note
relative odontoid apex.
Below line
Basilar impression when odontoid more
than maximum distance above. (Paget’s,
osteomalacia, etc.)
Right and left digastric grooves:
(a) line-odontoid distance
(b) line-C1/OCC joint distance
11mm
Males
8mm
Females
10mm
21mm
ADI
C1 anterior tubercle – odontoid
Adult
Child
3mm
5mm
George’s line
Alignment of posterior body
margins
Aligned
Posterior
cervical line –
more often
spinolaminar
line
Sagittal canal
dimension –
know that it
doesn’t work
Atlantoaxial
alignment
(rotation)
Spinolaminar junction lines
Aligned
Transverse ligament rupture or instability.
Trauma, Down’s, occipitalization of atlas,
etc. and inflammatory arthritis may
increase ADI. ADI should not gap at all
in flexion/extension.
A to P vertebral malpositions when line
not smooth; traumatic, >2mm suspect
instability (ligament laxity).
A to P vertebral malpositions when line is
not smooth, especially at C1 and C2; used
in conjunction with George’s line for
spinal canal stenosis (when less than
12mm).
Spinal stenosis when less than 12mm.
Intraspinal tumor when enlarged
C1 lateral mass – C2 articular
pillar margin alignment
Aligned
Jefferson’s or odontoid fractures or alar
ligament instability when margins
overlap. If C1 articular mass slides more
than 2mm over C2, suspect fracture [with
5 suspect dens fracture, 7 confirmed
dens fracture].
Cervical gravity
line
Vertical line from odontoid
apex
Lordosis or
angle of C-spine
Line from inferior endplates of
C7; line through anterior and
posterior tubercles of C1; take
perpendicular lines from each
above to obtain angle
Posterior margin of pharynx and
anterior margin of spine
Passes
through C7
body
40
AP displacement is a gross indicator of
gravitational stress at the cervicothoracic
junction.
Role unclear. Decreased following
trauma, muscle spasm, spondylosis, and
patient tucking the chin at time of
exposure
Digastric line
Retropharyngeal
space
1mm
(odontoid
not above
the line)
Posterior body – spinolaminar
junction lines
1mm
1mm
12mm
35
45
Basilar impression when odontoid is
above the line.
7mm - 20mm considered normal
C5, Pharynx above is 7
Trachea below is 20
Enlargement often from pus, blood, cells
X-ray Diagnosis Tri 6
Cobb’s angle
Risser-Ferguson
Thoracic
kyphosis
(straight back
syndrome)
Thoracic cage
dimension
Sacral base
angle
Lumbosacral
disc angle
Hadley’s S curve
Ferguson’s
gravity line,
Ferguson’s
weight line,
lumbar gravity
line
McNab’s line
Ullmann’s line
Interpediculate
distance
Eisenstein’s
method (line)
Unreliable.
Intertrochanteric
line
Klein’s line
Teardrop
distance
most inferior endplate of lowest
vertebra for first horizontal line,
and superior endplate of highest
vertebra for second horizontal
line; perpendicular lines form
each form an angle
Centers of end and apical
segments joined and the angle
measured
T1 superior endplate – T12
inferior endplate, then
intersecting perpendiculars and
the angle measured
Posterior sternum – anterior T8
body
8
Scoliosis named for the side (levo or
dextro) and degree at any level. 10 or
more is a scoliotic curve, less is a
convexity.
Scoliosis evaluation – this method
demands that a vertebra is a apex or base.
Kyphosis evaluation – often presents with
abnormal cardiac sounds.
Male 14cm
Female
12cm
11cm
9cm
18cm
15cm
Endplate of S1 to horizontal line
angle
Angle between opposing
endplates of L5 and S1
Line along the inferior surface
of TP along lamina along
articular process across joint
A perpendicular line is drawn
from the center point of L3
body
41
26
57
--
10
15
A line along the inferior
endplate
Should be
above
superior
articular
process
L5 behind
the line
Endplate line through S1,
perpendicular from sacral
promontory
Shortest distance between inner
surfaces of opposing pedicles
Tips of superior and inferior
articular processes joined.
Distance between posterior
midbody and this line (except at
L5)
Inclined line through neck of
femur – tangential line to outer
femoral neck, head just overlaps
laterally
Femoral head – teardrop
distance
Smooth
across joint
AP and Oblique views may be used.
Altered in various mechanical
pathologies
within 1 cm
of sacral
promontory
Variable
12 is normal
Straight back syndrome when the
distance is less than 13 cm in males and
11 cm in females. Normal > 13cm form
male and >11cm for female. Follow-up
measure for less than normal requires
cardiac exam.
Normal is 41 +/- 7; altered in various
mechanical pathologies.
Altered in various mechanical
pathologies
Injury / facet subluxation
Famous but not very useful; extension
malposition, normal variant.
Originally used on recumbent
positioning, weight bearing has an effect.
Detection of subtle spondylolisthesis
when L5 body crosses perpendicular line.
Decreased lordosis may give false (+).
Widened in intraspinal tumors, fracture /
trauma; narrowed in spinal stenosis.
Always wide on kids.
Spinal stenosis suspected when less than
15mm
Not reliable, indicates need for CT or
MRI. CT or MRI for (+).
15mm
Slipped femoral capital epiphysis when
head does not intersect line; often
presents with knee pain (not hip).
9mm
6mm
11mm
Early Perthes or other inflammatory joint
disease may widen the space more than
11mm or create a 2mm difference from
the normal side
X-ray Diagnosis Tri 6
Hip joint space
width
Protrusio
acetabuli
Presacral space
Shenton’s line
Boehler’s angle
Femoral neck
angle
Gleno-humeral
joint space
Fermoral head – acetabulum
distance.
a. superior
b. axial
c. medial (Kohler’s to head)
Pelvic inlet-outer obturator.
Acetabulum should be lateral to
the line
Soft tissue density between the
rectum and anterior sacral
surface.
Smooth curvilinear line along
medial femoral neck and
superior obturator border
Three superior points joined on
the calcaneus. Posterior angle is
measured.
Lines through the axis of the
femoral shaft and neck
Average humeral head-glenoid
distance (superior, middle,
inferior).
Acromialclavicular
Lateral tip clavical to medial
aspect acromion
Acromiohumeral joint
space
Solid white line of the articular
acromion to the head of
humerus
Gailula lines
(three arcs of the
wrists)
Draw proximal line of proximal
portion of proximal row; then
the distal portion of the
proximal row; and the proximal
portion of the distal row.
Endplate lines at opposing
segments. Measure from the
posterior body to point of
intersection.
Van
Akkerveeken’s
measurement
9
4mm
4mm
8mm
3mm
3mm
4mm
6mm
7mm
13mm
Child: 3mm
Adult: 7mm
1mm
2mm
5mm
20mm
30-35
28
40
120
130
2.5mm
2.1mm
4.1mm
3.7mm
7mm
11mm
4-5mm
Male:
3.3mm
Female:
2.9mm
9mm
Equal
measures
1.5mm
differ
Various joint diseases decrease these
distances:
Degenerative joint disease
Rheumatoid arthritis
Degenerative (OA) and rheumatoid
arthritis
Protrusio acetabule (Paget’s disease, etc.)
when acetabulum is medial to the line.
Soft tissue mass (tumor, infection,
hematoma), if exceeds maximum
distance.
Femur dislocation or fracture if line is
interrupted, femoral neck fracture,
slipped femoral capital epiphysis.
Calcaneal fractures may reduce the angle
to less than 28.
Coxa Vera: less than 120
Coxa valga: more than 130
Adding, dividing by three and comparing,
degenerative and crystal arthritis diminish
the space. Posterior dislocation may
widen it.
Distance divided by 2; traumatic shoulder
separation; degenerative arthritis
decreases distance. Separation and
resorption widens distance.
11mm or less rotator tear.
Arthritic changes,
dislocation/subluxation; rotator cuff tear
decreases distance. Subluxation and
dislocation increases distance.
Nuclear, annular and posterior ligament
damage if more than 1.5mm difference.
In slide testing for Dr. Kettner, if it’s in a box, it’s an infection.
Spondylolisthesis: Meyerding’s grading divides the sacral base into quarters with the relative position of the
posterior body of L5 determining grades I - IV (25%, 50%, 75%, or 100%).
A more accurate method is measuring the distance of slip [of the slipped vertebra] and dividing by the
length of the endplate of the stable (unslipped) vertebra.
Canal body ratio or Stenosis of vertebral canal: Take the ratio of the vertebral body to the canal; divide the canal
by the body. Less than 82% is stenosis. More accurate than sagittal canal dimension method above but plain
film is not good enough no matter what. CT or MRI is the best form of examination.
In blocked vertebrae: if congenitally fused, there is a C type cavity where the disc was, as opposed to a fused block
vertebra.
Vastine-kinney angle (sella turcica)
X-ray Diagnosis Tri 6
10
VanAkkerveeken and flexion and extension have been largely replaced by the more sensitive
compression/distraction study.
Lateral projection; draw two lines through and parallel to opposing segmental endplates until
they intersect posteriorly. The distance from the posterior body margins to the point of
intersection is then measured. Alternatively, the displacement can be assessed by measuring the
offset in the oppoosing body corners
Should be
Lateral bending study


may suggest ligament laxity and/or muscle spasm
poor correlation between this and clinical picture
PRINCIPLES OF X-RAY INTERPRETATION.
Seven categories of bone disease:
Congenital, trauma, arthritis, tumor, infection, hematologic, nutritional/metabolic/endocrine (VICTANE?).
Analysis of the lesion
- Skeletal location
- Position within bone
- Site of origin
- Shape
- Size
- Margination
-
Cortical integrity
Behavior of the lesion
Matrix
Periosteal response
Soft tissue changes
Joint changes
Preliminary analysis
- Clinical data: age, sex, race, history
- Number of lesions
- Symmetry of lesions
- Systems involved
Supplementary analysis
- Other radiologic procedures
- Lab exam
- Biopsy
Age (decades)
Size:
0-6 cm
6+ cm
Monostotic
polyostotic
Cortical destruction
Periosteal resction
Solid
Laminated
Spiculated
Codman’s
Destruction
Geographic
Motheaten
Perireactive
Margins:
Sharp
Inperceptiple
Matrix
Soft tissue mass
Joint space
Begign
123
Primary
1234567
Secondary
4567
+++
+
+++
+
-
+
+++
+++
+
+++
+
+++
++
+++
+++
+++
++
++
+
++
+++
++
+
+
+++
-
+
+++
+++
+++
+++
+++
+++
-
+
+++
++
+++
-
+
+++
+
-
X-ray Diagnosis Tri 6
11
OSTEOLYTIC BEHAVIOR
Geographic lesion
Solitary
Greater than 1 cm
Sharp margin
Motheaten lesion
Multiple
2-5mm
ragged margins and coalescence
imperceptible transition
permeative lesion
multiple
less than 1mm
imperceptible transition
OSTEOPLASTIC BEHAVIOR
Diffuse lesion
Homogenously sclerotic (“ivory”)
Obliterated corticomedullary junction
Localized lesion
Single or multiple
Irregular, hazy border
Asymmetrical
MIXED BEHAVIOR
Both osteolytic and osteoblastic features
Table 7.1 - Normal Laboratory Values:
Acid phosphatase, alkaline phosphatase, calcium, CBC (hematocrit, hemoglobin, RBC, WBC), C-reactive
protein (CRP), ESR, phosphorus, protein (total or fractions [albumin, globulin]), special antigens (HLA B27,
RA factor), uric acid.
DYSPLASIA
Achondroplasia – most common form of dwarfism. “champagne glass” pelvis or “wine glass” pelvis; normal is
brandy snifter. A more rectangular shaped pelvis, the scapula also appears blunted; can demonstrate coxa vara
or valga; interpedunculate space narrowed and central canal stenosis with a scalloped appearance on lateral Xray via dural actasia (due to a lack of room for the cord allowing for the pulsation of the CSF to impress on the
vertebra) gives a bullet shaped vertebra. most common complication is central canal stenosis and DJD in the
adult (multiple laminectomy often necessary); frequent cause of neonatal death stenosis of foramen magnum.
This is a bilateral process with grossly short bones; proximal more than distal affected and longer bones more
than shorter bones yields the rhizomelia classification. Higher, flatter forehead; depressed nasal ridge;
protruding buttocks and abdomen; incomplete extension of arm (shallow olecranon fossa); champagne glass
pelvis, short extremities (rhizomelia), diminished interpeduncular spaces AP view; affects endochondral bone
development (achondroplasia) but normal intramembranous development; spine typically acquires normal
length; and trident hand is a classic X-ray finding (when patient completely opens hand, the thumb is off by
itself, first two fingers and second two fingers group).
Overall etiology unknown; 80% considered spontaneous. There are lethal forms, serious complications in adult;
normal intelligence.
Cleidocranio dysostosis (dysplasia) – common appearance of MID-LINE defects. Appearance of lots of wormian
bones in occipital region with a lack of lambdoidal suture. They do not qualify as a dwarf though short and
with a little larger head and smaller face than usual (altered craniofacial) and depressed shoulder. Cleft palette,
cleft lip, missing pubic symphasis, prevalent wormian bone, small face in relation to skull, drooping shoulders
and slender neck, high mobility of shoulders allowing for a large amount of self love arm wrapping. This is not
rare, though not common. Smaller ribs at the top giving a funnel shaped chest cavity. 10% have congenital
absence of the clavicle.
X-ray Diagnosis Tri 6
12
Marfan’s syndrome – arachnodactyly; long, slender foot and hand bones. Occular abnormality (lens dislocation)
and very tall (over 6 foot). There is a tendency for dissecting aortic aneurysms. Look for the thumb sign: fold
your thumb into your hand and close your fingers around it and push the thumb under; typically you can see the
entire distal phalanx sticking out the other side. Ligamentous laxity. Equal prevalence is equal between men
and women. Body habitus is on the thin side with low body fat and joint laxity. About 45% have scoliosis.
Poor dentition with lots of dental caries. Consider, upon seeing a scoliotic child, how tall are they, are they
wearing glasses, how are your teeth, can you bend your thumb, do you have a murmur. Often these people have
valvular and chamber deformities in the heart. Enchondral bone growth exagerated, though intramembranous is
pretty normal. Pectus excavatum results in heart disposition. Common and clinically recognizable. First site of
aortic aneurysm is the arch (first highest pressure zone in the aorta) second is in the bifurcation of the common
iliacs (the second highest pressure zone in the aorta).
Osteogenesis imperfecta (OI) – hands demonstrate arachnodactyly, short stature due to multiple fractures causing
premature closure of growth plate. Bone has a thin cortex and lack of density in trabecula. Fractures can lead
to subperiosteal bleeding leading to a large, exuberant callous formation. Bilaterally curved femurs, the degree
of bowing can indicate the severity of affliction. Trivial trauma can produce fracture. Osteoporosis with great
fragility, 90% have a blue sclera due, and abnormal dentition. There are two forms:
Congenitive: worse, recognized at birth, higher mortality rate, if they live past infancy they are profoundly
affected as adults.
Tartiform: comes out incidentally later.
A form of brittle bone disease along with osteopetrosis.
SCLEROTIC DYSPLASIAS
Maloryostosis – part of the bigger group of sclerosing ostoses. Adds cortical bone endogenously and exogenously.
This has more cortical bone than is normal and increased density inside the bone without changing the contour
of the bone. Most findings are incidental (found during investigation of a different complaint). Symptomology
produces through compression of soft tissue, nervous tissue, tendinous tissue, etc. offering a molten waxed
appearance. Most common in the extremities.
Osteopetrosis – “bone-within-a-bone” polyostotic, increased densities a.k.a. chalk bone; very unusual. Bone has no
exaggerated osteoblastic activity. Trivial trauma can produce fracture. A form of brittle bone disease along
with OI.
Osteopoikelosis – polka-dot appearance of bone on plain film, normal bone scan, no pain syndromes, does not
appear to change the bone strength.
KNOW A BUNCH OF THE FOLLOWING STUFF:
Asphyxiating dysplasia
Aperts with brachycephaly (short skull) not bradycephaly,
Schaphocephalic (boat head) normal coronal suture growth and early closure of sagittal suture.
Turycehpaly
Underdeveloped distal palanges, bulbos nose and thick, coarse hair = trichorhinopalangeal
Shortened metacarpals.
Stippled epiphysis – multiple growth centers
Spondyloepiphyseal dysplasia – heaped up appearance of the body of the vertebra.
Angleman’s disease (progressive diaphysiseal dysplasia)– demonstrates less density than maloryostosis (no
candlewax appearance) and is internal only.
Picnodysostosis – very small, pinched faces (elfin), more head than face and increased density within the bone.
Osteolysis (resorption of bone).
Acroosteolysis – know the film. With skin induration and retraction of soft tissue and difficulty in swallowing is not
picnodysostosis but is scleroderma.
Most typically, an acquired blocked vertebra will produce greater degrees of DJD.
X-ray Diagnosis Tri 6
13
Developmental cleft – a normal “step” in a vertebral body
Limbus vertebra – when the nucleus pulposis goes through the ring apophysis (growth ring) of the vertebra instead
of into the endplate or through the longitudinal ligament. It is not mobile because the sides are still in fusion
with the remainder of the ring and body.
Block vertebra is an indication for flexion/extension series to examine ADI instability. The classic block will
demonstrate a “wasp” waist at the rudimentary disc area.
CONGENITAL
Hyperostosis internus (the whole inner table is bigger/thicker); frontalis is limited to the frontal bone.
Parietal foramen – congenital failure of the fontanels to ossify.
Hypoplasia of the frontal sinus; clinical significance – none. There are two spikes to sinus formation: just before
puberty and just before skeletal maturity. Concern for a benign frontal osteoma.
Occipitalization (craniovertebro synostosis)– occiput and C1 fusion; see what appears as a foramen like
radiolucency in that area. Express concern for transverse ligament damage; pay attention to the ADI
(accumulated microtrauma will increase the ADI resulting in weakening transverse ligament possibly resulting
in guillotine). This condition calls for flexion/extension cervical series.
Spodylo-schisis – modified submental - failure (agenesis) of both anterior and posterior tubercle C1.
Paradental sulcus
Frontal suture closure result in taller head; mid sagittal closure results in craniocephaly.
Ponticulus posticus (arcuate foramen) – a physiologic pattern of soft tissue calcification:
Serum Ca++
Tissue
Physiologic
normal
normal
Metastatic
metastatic
normal
Dystrophic
normal
abnormal
About 10% of patients will have recognizable complaints associated with this. This is particularly
important with concern to VBAI.
1.
2.
3.
Os odontoidium – failure in ossification of dens to body C2.
Cervical digit – an articulation on/of a rib.
Cervical ribs
Sacral agenesis
Posterior scalloping – from achondroplasia with dural ectasia; or from NF
Geriatric:
Things you expect to see: OP, compression, DJD, change in contour
Surprises that are common to see: congenital anomalies, benign tumors (fibrous), Paget’s disease
License stealers: Metastasis, AAA, infection (lung or bone)
Old men: less OP
Young adult:
Things you expect to see: trauma, posture abnormalities.
Surprises that are common to see: Fibrous lesions, congenital anomalies
License stealers: infection
X-ray Diagnosis Tri 6
14
Pediatrics:
Things you expect to see: no abnormalities.
Surprises that are common to see: Fibrous lesions, congenital anomalies
License stealers: Metastasis, infection
Ununited apophysis.
Cervical digit.
Sprengel’s – unilateral elevation of scapula; actually, failure of scapula to descend.
Omovertebral bone – often seen with sprengel’s. Often associates Klippel-Feil syndrome, blocked vertebra, webbed
neck
Rhomboid fossa – a muscular impression on X-ray. No clinical consequence.
Hemivertebra – only neatly triangular when drawn.
Scrambled spine, also a structural scoliosis.
Butterfly vertebra – missing primary ossification centers in the body, apparently migrating to the levels above and
below.
Intrathoracic rib – unlikely to produce any complications.
Synostosis of rib (bifid rib, or costal synostosis). Failure to separate.
Elongation of L5 TP, considered a physiologic variant most likely calcification of iliolumbar ligament.
Spina bifida in the lumbar vertebra seems to associate with increased disc pathology.
Reversed thoracic kyphosis or thoracic lordosis: recommendable to perform thoracic cage mensuration. If linked
with a heart murmur, then straight back syndrome. If there is a heart murmur it is likely a result of floppy valve
syndrome. High percentage have pathology requiring valve replacement.
Costochondral ossification – physiologic calcification – everything (serum and tissue calcium) is normal.
Thoracolumbar transitional ribs.
Notochordal persistency resulting in cupid’s bow.
Winking owl sign – metastasis (most common) or congenital. Sclerosis of the contralateral indicates congenital
because it takes a long time to sclerose.
There is an apparent correlation between spina bifida and DJD.
Springboard divers, interior lineman, gymnasts are at high risk for acquired splondylolysis.
If flexion/extension demonstrate 3% or more translation you confirm unstable listhesis; less than 3% does not rule in
or out anything.
Oppenheimer’s ossicles – nonunion of growth centers.
Lordodic sacrum
Injection granulomas [from arthritic injections in the gluteus] called dystrophic calcification (regularly seen in
patients).
Pseudotumor of the pelvis – results from observation of the growth plate between the ischial and pubic rami.
Fabella – sesamoid-like bone in lateral gastroc often confused with synovial chondroplasia.
Rockerbottom foot – missing tarsal bones
Bipartate sesamoid bones.
Tarsal coalition – bony bars in the tarsals.
Pseudotumor of the humerous – lucency that results from the attachment of rotators – it disappears on baby-arm Xray
Supracondylar process – found on the humerous and points toward the elbow joint (normal variant). Often confused
with osteochondroma – points away from the joint, found anywhere on the body, and has a condral cap.
Maudline’s deformity – ulnar deviation of wrist
Ulna minus – short ulna.
Ununited growth center of ulnar styloid process.
Radius minus.
Synostosis – failure of the bones to separate.