imaging final Flashcards
1
Q
indications for imaging lumbar spine
A
trauma
pain radiating to legs
limitation in motion
planned or prior surgery
eval of primary/secondary malignancies
arthritis
osteoporosis
compression fractures
eval of kyphosis and scoliosis
suspected congenital anomalies and syndromes
eval of spinal abnormality seen on other imaging
follow-up of known abnormality
suspected spinal instability
2
Q
lumbar spine projections
A
AP
lateral
right and left oblique
coned lateral view of lumbosacral articulation
3
Q
right and left posterior oblique (Lspine)
A
right side structures on RPO
left side on LPO
posterior shows downside facet joints closest to image receptor
4
Q
anterior oblique (Lspine)
A
shows upside facet joints farther from image receptor
5
Q
R and L obliques need what to distinguish them
A
marker to determine left or right
6
Q
scottie dog of oblique L-spine
A
nose - transverse process
eye - pedicle
ear - superior articular facet
foreleg - inferior articular facet
body - lamina and spinous process
tail - superior articular facet of opposite side
hind leg - inferior articular process of opposite side
7
Q
what is best choice for imaging trauma at lumbar?
A
CT
TAP body scan
8
Q
when is MRI indicated/not indicated in trauma at Lspine
A
in - if neural compromise
not - if CT is normal
9
Q
predominate site for L spine vertebral fractures
A
thoracolumbar junction (T11-L2)
because they are transitional from fixed thoracic to mobile lumbar
10
Q
spondylosis: definition and 3 causes
A
defect at pars interarticularis
congenial
traumatic
stress fracture by chronic strain (most common)
11
Q
spondylolisthesis
A
forward displacement of vertebra on the one beneath it
12
Q
retrolisthesis
A
posterior displacement on the one beneath it
13
Q
incidence of spondylolisthesis
A
~5-10% of people
children and adolescents typically affected
lower lumbar levels most often involved - L4-L5 L5-S1
14
Q
spondlylolisthesis can be the consequence of:
A
spondylolysis
15
Q
spondlylolisthesis can result from:
A
congenital or developmental aberrations
pathological processes
degenerative changes
16
Q
clinical presentation of spondlylolisthesis
A
pain after athletic activities
lumbar flexion reduces pain
palpation of SPs can reveal rotation of depression
SP sign correlated with radiologic findings to determine type
17
Q
degenerative spondlylolisthesis
A
entire vertebra slips forward as a unit
~step off of Sp is below level of slip
18
Q
fracture spondlylolisthesis
A
forward slip of vertebral body, pedicles, and superior articular processes
inferior processes, laminae and SPs remain in normal position
~step off is above level of slip
19
Q
treatment of spondlylolisthesis
A
restriction of extension loads
flexion can be self-reducing and relieve pain
bracing
surgical fusion in cases of neurological compromise or persistent pain that does not respond to conservative
20
Q
degenerative pathologies associated with lumbar spine
A
spinal stenosis
IVD herniations
21
Q
DDD radiologic findings
A
decres disk space height
osteophytes at vertebral endplates
schmorl’s nodes
vacuum phenomenon
22
Q
DJD radiologic findings
A
decres z joint space
sclerosis
osteophytosis at joint margins
23
Q
spondylosis radiologic findings
A
osteophytes visible as readiodense irregularities at vertebral joint margins
24
Q
spondylosis deformans radiologic findings
A
claw like spurs cupping towards IVD at more than one level
25
DISH radiologic findings
flowing ossification of at least four contiguous vertebrae
preservation of disk height and absence of DDD
absence of sacroiliitis or z joint DJD
26
lumbar stenosis
narrowing of spinal canal secondary to ST or bone enlargement
27
classification of lumbar stenosis
congenital
acquired
by anatomic region involved
28
congenital lumbar stenosis
achondroplasia
morquio's syndrome
down's
idiopathic stenosis
29
acquired lumbar stenosis
prior surgery
spondylolisthesis
infection
tumor
spinal deformity secondary to trauma
bulging og annulus
herniation of IVD posteriolaterally
PLL thickening
PLL ossification
hypertrophy of z joints
DJD of z joints
hypertrophy of ligamentum flavum
epidural fat deposition
spondylosis of vertebral joint margins
uncovertebral joint hypertrophy
metabolic/endocrine disorders
30
3 anatomical classifications of lumbar stenosis
central spinal canal
invertebral foramen
subarticular or lateral recesses
31
incidence of lumbar stenosis
1/4 of asymptomatic population under 40
most over 60 have some degree
symptomatic affects men > women 40-50 yo
central canal narrowing most prevalent at L4
32
etiology of degenerative stenosis
osteophytes at joint margins
bony hypertrophy of pedicles, laminae and z joints
IVD bulging
displacement of entire vertebra
thickening of ligamenta flava
33
normal AP diameter of spinal canal in adult men
cervical spine C3-C5: 17-18 mm
c-spine C5-C5: 12-14mm
T-spine: 12-14mm
L-spine: 15-27mm
34
clinical presentation of spinal stenosis
severe cases result in disability
most serious complication is central cord syndrome
35
central cord syndrome
incomplete spinal cord lesion associated with hyperextension injuries and results in proportionately greater loss of motor function to upper extremities than lower extremities with variable sensory sparing
36
cervical spine stenosis presents with
long tract and radicular signs
headaches
pain
radiating electric-like shock sensations elicited with cervical spine flexion
37
concurrent cervical and lumbar spinal stenosis can present with
gait disturbance
myelopathy
radiculopathy
38
lumbar spine stenosis presents with
diffuse unilateral or bilateral LBP and/or LE pain
numbness
weakness
39
simian stance
posture of trunk, hip and knee flexion
40
neurogenic claudication:
congestion of blood vessels at stenotic level
exacerbated by standing and spinal extension
41
vascular claudication
exacerbated by exercise and improved with standing
42
disk herniation differentiated clinically by aggravating factors:
pain by sitting, flexion, lifting, valsalva
relieved by walking
pain from spinal stenosis not affected by any of those maneuvers and aggravated with walking
43
diagnosis of pts with lumbar spinal stenosis
age 60-70 - 2
> 70 - 3
symptoms present > 6 months - 1
symptoms improve when bending forward - 2
symptoms improve when bending backward - -2
symptoms exacerbated while standing up - 2
intermittent claudication (+) - 1
urinary incontinence - 1
44
clinical bottom line for LSS
> 7 indicates a small meaningful shift in probability
< 2 indicated moderate shift that does not have LSS
45
what images significant for finding spinal stenosis?
conventional radiographs significant for exclusion or assessment
46
advanced imaging in lumbar spine
CT - spinal stenosis
myelography - constriction of thecal sac
MRI - assessment of thecal sac and contents
SPECT - discriminating stenosis from medical disease, infections, tumors
47
treatment of stenosis
analgesic medications
NSAIDs
epidural steroid injections
PT for strengthening and flexibility exercises
48
IVD herniations
defined as extension of NP through AF and beyond adjacent vertebral margins
49
incidence of IVDH
most common in 25-45 yo
men > women
predominance in smokers, obsese, exposure to vehicular vibration
most common at lumbar spine - 90% at L4-L5
rare in thoracic spine
cervical IVDH occur at 90% frequency at C5-C6
50
clinical presentation of IVDH
cause LBP and referred or radicular pain
exacerbated with flexion, sitting and valsalva
nerve root pressure = loss of muscle strength
rarely cauda equina syndrome can develop - emergency
51
history and physical examination data of cauda equina syndrome
urine retention
fecal incontinence
saddle anesthesia
sensory or motor deficits in the feet
52
radiologic findings of IVDH
unnecessary in first 4-6 weeks
20-30% are asymptomatic
many improve with conservative treatment in 4-6 weeks
imaging when conservative treatment fails
exceptions are CES
53
advanced imaging for IVDH
myelography
CT myelography
diskography
CT
MRI
54
treatment for IVDH
conservative measures
~PT
~analgesics
~short term bedrest
~restricted activities
only small percentage require surgery
55
radiographic hallmarks at DJD at SI joint
decreased joint space
subchondral sclerosis
osteophyte formation at joint margins
only lower halves of joint space image represent synovial portion of joints
thus evaluation of DJD confined to lower half of joint space
56
ankylosing spondylitis
inflammatory arthritis characterized by joint sclerosis and ligamentous ossification
manifests first in stiffness of SIJ and extends to L and T
57
prevalence of ank spon
men affected seven times more than women
onset in 20s
early diag by blood work
58
radiologic findings of ank spon
abnormal narrowing of upper half of SIJs
squaring-off of anterior borders of vertebral bodies
later, syndesmophytes form bridging vertebral bodies
known as bamboo spine
59
indications of hip radiologic examination
trauma
osseous changes secondary to metabolic disease
systemic disease or nutritional deficiencies
neoplasms
infections
arthropathies
preoperative, postoperative, follow up studies
congenital syndromes and developmental disorders
vascular lesions
evaluation of soft tissue
pain
correlation of abnormal skeletal findings on other imaging
60
recommended projections of hip
AP and lateral
61
what is osseous pelvis evaluated with?
AP projection
62
iliopectineal/iliopubic line
represents anterior column
line from sciatic notch to pubic tubercle
63
ilioischial line
represents posterior column
line from iliac notch to inner surface of ischium representing posteromedial margin of quadrilateral surface of iliac bone
intersects teardrop
64
anterior lip of ace
represents anterior wall of ace
65
posterior lip of ace
represents posterior wall of ace
66
acetabular roof
represents superior cortical aspect of ace cup
corresponds to major weight-bearing portion of ace
67
anterior ace rim
represents anterior margins of ace cup
68
posterior ace rim
represents posterior cortical rim of ace cup
69
radiographic teardrop
seem on medial ace formed by cortical surfaces of pubic bone and ischium representing anteroinferior ace
70
klein's line
drawn along lateral femoral neck intersecting the femoral head bilaterally
71
shenton's hip line
should be possible to draw smooth curve along medial and superior surface of ob foramen to medial aspect of femoral neck
72
iliofemoral line
smooth curve along outer surface of ilium that extends inferiorly along femoral neck
73
femoral neck angle (angle of inclination)
intersection of line drawn through center of femoral shaft and line drawn through center of femoral neck
normal 130
coxa vara <130
coxa valga >130
74
DJD of hip
aka osteoarthritis
most common disease in the hip
75
primary and secondary of DJD at hip
pri: developing without a clear precursor
sec: directly related to trauma or pathology
76
secondary DJD caused by:
fracture
paget's disease
epiphyseal disorders
congenital dislocation
AVN
other inflammatory arthritides
77
clinical presentation of DJD in hip
progressive pain and loss of ROM
impaired ambulation
78
radiologic findings of DJD at hip
joint space narrowing
sclerotic subchondral bone
osteophyte formation at joint margins
cyst or pseudocyst formation
migration of femoral head
79
what do cysts result from
degeneration of articular cartilage
loss of buffering effect results in microfractures
intrusion of synovial fluid into bone
show up as radiolucent lesions
80
what are cysts in acetabulum called?
egger's cysts
81
most common pattern of altered surface when femoral head migrates in DJD
superomedial to normal position
82
treatment of DJD is designed with goals of:
decres pain
restoring flexibility and strength
reserving functional activities and amb with ADs to unload joint from full weight-bearing stresses
83
surgical treatment of DJD
wedge osteotomy
femoral head and neck resection
hemiarthroplasty to replace fem head
total arthroplasty
hip resurfacing - young with goo bone density
84
hip resurfacing
metal coating cemented over femoral head and metal liner impacted into ace
liner has coating to promote ingrowth of bone too further stabilize it
85
rheumatoid arthritis of hip
progressive, systemic, autoimmune disease
3X more in women
onset most common in young adulthood
86
clinical presentation of RA in hip
morning joint stiffness
bilateral and symmetrical swelling of joints
pain and functional disability
rheumatoid nodules
positive rheumatoid factor test
radiographic changes consistent with RA
87
radiologic findings of RA in hip
osteoporosis of periarticular areas
symmetrical and concentric joint space narrowing
articular erosions
synovial cysts
periarticular swelling and joint effusions
axial migration of femoral head
acetabular protrusion
88
where is osteoporosis first seen in hip?
femoral head
89
what causes acetabular protrusion
concentric joint space narrowing promotes axial migration of femoral head into acetabulum
90
best projection for synovial cysts
MRI
91
distinct difference between DJD and RA in hip
RA has minimal or absent reparative process
sclerotic subcondral bone and osteophyte formation are not features of RA
92
RA deformities
boutonniere deformity
swan neck deformity
93
OA deformities
heberden's node
bouchard's node
94
pharmacological treatments for RA
NSAIDs
coricosteroids
gold salts
immunosuppressive drugs
95
conservative treatment for pain and disability for RA
rehab focuses on pain modalities, splinting, adaptive functional and amb devices, and exercise to promote strength/ROM to minimize deformity
96
surgical treatment for RA
total arthroplasty
97
AVN of femur
interruption of blood supply to femoral head causing bone tissue death
osteochondritis dissecans: local segment of bone
epiphyseal ischemic necrosis: affects entire epiphysis in growing child
98
where is most common location for epiphyseal ischemic necrosis?
proximal femur
99
three categories of AVN
compression or disruption
blood vessel occlusion
blood vessel blockage
100
causes of epiphyseal ischemic necrosis at femoral head
called legg-calve-perthes disease
seen in young boys around 6 yo
idiopathic AVN
101
clinical presentation of LCP
synovitis or inflammatory response of hip joint
non-specific dull pain in joint, thigh, leg
adults exhibit limited joint motion and progressive painful limp
children exhibit painless, slowly evolving limp
~waddling type gait
102
radiologic findings of LCP
appear normal for several weeks
one of first signs: radiolucent crescent
crescent parallel to superior rim of femoral head subjacent to articular surface
103
what are characteristic signs of initial necrotic processes?
sclerosis and cyst formation at femoral head
104
radiographic findings of advanced AVN?
femoral head collapses or appears flattened
entire femoral head becomes more radio-dense
at advanced stage, joint is compromised
105
what do radionuclide bone scans identify?
increased uptake at sit of lesion soon after injury
106
what is the most appropriate study for early diagnosing AVN?
MRI
107
when is conservative treatment of AVN most successful? (hip)
in younger pts.
they possess healthier, more adaptable blood supply
108
how to revascularize AVN with conservative treatment? (hip)
prolonged avoidance of weight bearing
traction
bracing
casting
exercise
109
surgical treatment of AVN at hip
drilling into femoral head to quicken revas
grafting healthy bone into drill hole to assist repair
varus derotation osetotomy
last resort - joint replacement
110
ottawa knee rules
age greater than or equal to 55
isolated patella tenderness
tenderness at head of fibula
inability to bear weight immediately after
111
pittsburgh knee rules
fall or blunt trauma
age <12 or >50 - immediate yes
not able to walk four weight bearing steps
112
which knee rules more specific
pittsburgh
113
images ordered at knee if
joint effusion after blow
inability to walk without limping
palpable tenderness over patella or fibular head
inability to flex to 90
114
isolated meniscal tears present with
intermittent clicking and eventually blocking of motion
effusion
pain
115
how are menisci seen on MRI?
low intensity
tears are high intensty
116
most common meniscal tear
vertical
117
bucket tear (meniscus)
longitudinal extension of vertical tear
118
meniscal tears in older pop
usually horizontally oriented
119
clinical presentation of tear of collateral ligs
pain
joint effusion
instability
120
LCL MOI
varus force
121
MCL MOI
valgus force
associated with medial meniscus tear
122
O'Donoghue's terrible triad
MCL
med meniscus
ACL
123
most revealing image for knee ligaments
T2 MRI
124
how do ligs look on T2 MRI
low intensity
abrupt discontinuity would show lig tear
125
tears of cruciate ligs (women vs men)
women affected 8x more than men in same activities
126
PCL MOI
external forces that strike anterior aspect of knee
127
ACL MOI
non-contact forces that place great valgus and rotary stresses on knee
hears pop of rupture
128
best image for cruciate ligs
sagittal MRI
129
what is the most frequently injured joint?
ankle
only small percentage actually have a fracture
130
ottawa ankle rules
unable to bear weight
point tenderness in malleolar zone, mid-foot, base of fifth MT, or navicular
100% sensitive
131
adavanced imaging for ankle when:
plain insufficient to guide treatment
after radio findings are neg when further injury suspected
132
what percentage of all ankle sprains are inversion?
85%
133
larger mag inversion sprains associated with:
lig rupture or avulsion
ankle instability
functional impairment
134
what ligs do inversion stresses sprain?
LCL
anterior tibfib
calcaneofib
without bony involvement
135
spectrum of injuries from inversion stresses
LCL sprain
LCL rupture
transverse fracture of lateral malleolus
fracture of med mall with rupture of LCL
136
eversion sprains
stress MCL
associated with bony damage
137
spectrum of injuries from eversion stresses
MCL sprain
MCL rupture
med mall fracture
lat mal fracture with MCL rupture
138
other structures that sever sprains can disrupt
avulsion fractures pull ligs at attachments
tearing of dis tibfib syndesmotic complex
instability- tearing ligs
139
when is radio image needed in ankle
fracture is suspected
140
maisonneuve fracture
insterosseous membrane involved and sprial fracture at prox fib
141
treatment of ankle sprain
restore stability
142
ankle fractures are in combo with:
lig rupture
avulsions
other fractures
143
ankel fracture MOI
axial or rotational loading
144
factors determining injury pattern in ankle fracture
instability
age
bone density
comorbidity to ST
position of foot at time of loading
mag, direction, rate of loading
145
unimalleolar
indicating fracture of either lat or mad malleolus
146
bimalleolar
fracture of both lat and med mall
147
trimalleolar
both malleoli and post tib
148
how to image stress fractures
MRI
149
treatment of ankle fractures
stabilize
immobilize or surgery
150
complications of ankle fractures
non-union or degen joint changes
151
frequency of talar fractures
second to calcaneal
152
MOI of talar fractures
dorsiflexed foot
ex. slam on breaks in collision
153
interarticular fractures
almost all because 3/5 of talus covered art cart
154
radio eval of talus fracture
plain films good most of the time
CT or MRI with plain neg or pre-op
154
treatment of talus fracture
non-op - short leg cast for 8-12 weeks, NWB 6 weeks
op - often ORIF
155
complications of talus fracture
post traumatic arthritis of ankle and subtalar
bad blood supply because no muscle attach to it
predisposed to AVN
156
osteochondral defect
focal areas of articular damage and injury of adjacent subchondral bone
157
osteochondritis dissecans
dur to repeated microtrauma
result of aseptic separation of osetochondral fragment
2:1 male to female ratio
158
location of osteochondral defect
femoral condyle
humeral head
talus
capitulum of humerus
159
clinical presentation osteochondritis dissecans
asymptomatic to sig pain and locking
joint effusion and synovitis present
160
treatment of osteochondritis dissecans
spontaneous healing unless there is an unstable fragment
results are only fair
161
accessory bones in foot
form due to failure of ossification centers
30% of adults
not always symmetrical
increased density
162
describe protection and stability of shoulder
less mechanical protection and less bony stability than any other large joint
163
MRI for acute shoulder pain when?
initial radiographs normal
RC pathology, instability or labral tears suspected
164
when is shoulder CT recommended?
if MRI unavailable or contraindicated
165
RC MOI
GH dislocation
FOOSH
forceful abduction of arm
impingement
166
most common RC tear
involves hypovascular critical zone in supraspinatus 1 cm above insertion
167
predictor variables for impingement syndrome
positive hawkins-kennedy impingement sign
positive painful arc sign
positive infraspinatus muscle strength test
168
predictor variables for full thickness RC tear
positive painful arc sign
positive infraspinatus muscle strength test
positive drop arm test
169
past radio eval of RC tears
arthrography
intact- contrast confined to joint capsule
complete tear- contrast travels up to bursa
170
present radio eval of RC tears
MRI - more info and noninvasive
US
171
changes secondary to RC tears
irregularity of greater tuberosity
narrowing of distance between acromion and hum head
erosion of inferior aspect of acromion
172
conservative treatment if RC tears
rest
NSAIDs
cortison injections
most need surgery
173
complications of RC tear
degen changes at GH and AC
failure to regain full ROM and strength following surgery
174
SICK scapula
scapular malposition
inferior medial border
coracoid pain and malposition
dyskinesis of scapula
175
SICK scapula symptoms
postero-superior scapular pain
anterior shoulder pain
proximal shoulder pain
c spine pain
TOS
176
three types of dyskinesis
1: inferior medial scapular prominence
2: medial scapular border prominence
3: superomedial border prominence
177
which types of dyskinesis associated with SLAP lesions
1 and 2
178
which type of dyskinesis associated with impingement and RC lesions
3
179
two basic functions of labrum
deepen glenoid fossa
attachment points for ligaments and biceps tendon
180
symptoms of labral tear
pain with overhead movements
clicking or catching
instability
181
MOI of labral tear
dislocation
forceful lifting
FOOSH
repetitive movements
182
most appropriate procedure to assess instability and labral tears
MR arthrography
CT arthrogrphy is second choice
183
treatment of labral tears
most heal conservatively because of rich oxygen supply
184
what labral tears require surgery
avulsions to glenoid rim
debride minor tears
biceps tenodesis - changes insertion of biceps
185
silhouette sign
loss of normal interference between air and ST
can localize lesion to a specific lobe of lung
186
cardiothoracic ratio
estimate of heart size
in adults, width of heart should be less than half of width of chest at level of diaphragm
187
mediastinum
space between lungs
188
hilum (lung root)
where bronchi, arteries, veins, and nerves enter and exit lungs
189
diaphragm
separates abdominal cavity from thoracic cavity
seen at 10th intercostal space
190
costophrenic angles
sharply pointed downward indentations between each hemidiaphragm and adjacent chest wall
191
routine chest exam
erect PA
erect left lateral during full inspiration
192
PA chest
view from apices down to costophrenic angles
193
lateral chest
from sternum anteriorly to posterior ribs
194
diagnostic categories
lung field abnormally white
lung field abnormally black
mediastinum abnormally wide
heart abnormally shaped
195
when is lung field abnormally white
pneumonia
water density consolidation
silhouette sign
air bronchogram signs
196
when is lung field abnormally black
pneumothorax
common following penetrating chest wounds
affected lung field appear black
deep sulcus sign
mediastinal shift from radiolucent lung field
197
when is mediastinum abnormally wide
aortic dissection - tear in inner layer of aorta
most common site in ascending aorta
198
other signs of aortic dissection
obliteration of normal arch shape
downward slant of left main bronchus
tracheal deviation to right
199
when is heart abnormally shaped
congestive heart failure
vascular redistribution
kerley b lines
peribronchial cuffing
pleural effusion
bat wing or butterfly pattern
