Radiology

Question 1

Label picture 6 in trauma section - shenton line, iliopectineal, ilioischial and teardrop

Answer 1

See picture 7

Blue = shenton
Green = iliopectineal
Yellow = ilioischial
Red = teardrop

Question 2

Label picture 8 in trauma section with the lines used to interpret C spine X-ray (5)

Answer 2

See picture 9

Pink= prevertebral soft tissue shadow : between c2-c4 shouldn’t be > 3-5 mm
Blue = anterior vertebral body line :must be in lordosis, smooth, parallel.
Green = posterior vertebral body line
Yellow - spinolaminar line
Black = posterior spinous line. Must converge at 1 point.

Question 3

Label picture 70 in trauma section

Answer 3

See picture 71

Question 4

Identify pathology picture 39 in trauma section

Answer 4

1. Details: lateral xray of the Thoracolumbar spine of Mr x on date y
2. Adequacy - adequate.
   •t11/t12 - sacrum with vertebral bodies, facet joints, pedicles and transverse processes clearly visible. Good penetration.
3. Alignment
   • Anterior vertebral line disrupted from l1 to L3 indicating fracture
   . Posterior vertebral line intact

4 loss vertebral height of l2 = compression fracture associated with osteoporosis or burst #

5. Vertebral spaces normal
6. Vertebral end plate superior and inferior continuity.
   • superior end plate of l2 disrupted
   • end plate sclerosis and osteophytes formation = spondylosis
   • no fragments seen so unlikely burst #
7. Posterior elements
   • pedicles: normal so unlikely burst #
   • laminae normal
   • spinous processes: normal

Pathology: compression # of l2 with spondylosis

Question 5

Identify pathology picture 40 in trauma section

Answer 5

1. Details: ap and lateral xray of the lumbar spine of Mr x on date y
2. Adequacy = adequate
   •t11/t12 - sacrum with vertebral bodies, facet joints, pedicles and transverse processes clearly visible. On ap, spinous processes central and transverse processes equal distance.
3. Alignment
   . Ap: vertebral bodies alignment disrupted at l2. spinous processes aligned
   • lateral: disruption of ant and post vertebral body lines
   • therefore fracture

4 loss vertebral height at L2 = compression fracture associated with osteoporosis or burst #

5. Vertebral spaces
   • narrowed at L1/L2
6. Vertebral end plate superior and inferior continuity.
   .L2 superior end plate disrupted
   • end plate sclerosis = spondylosis
7. Posterior elements
   • pedicles: normal
   • laminae normal
   • spinous processes: normal

Pathology: Compression #

Question 6

Identify pathology picture 41 in trauma section

Answer 6

Burst #

Question 7

Identify pathology picture 42 in trauma section and describe

Answer 7

• Sagittal View CT scan of lumbar spine of Mr X on the date of y
• Alignment: anterior and posterior Vertebral lines continuous and in lordosis
• loss of vertebral height seen therefore a fracture is present
• vertebral spaces increased
• vertebral end plates not continuous
• multiple fragments of the vertebral body seen
• fracture of posterior half of vertebral body
• no soft tissue abnormality seen

Pathology: burst #

Question 8

Identify pathology picture 44 in trauma section

Answer 8

1. Details: Sagittal CT scan of the lumbar spine of patient X on date Y
2. Adequacy = adequate
   •t11/t12 - sacrum with vertebral bodies, facet joints, pedicles and transverse processes clearly visible. On ap, spinous processes central and transverse processes equal distance.
3. Alignment
   posterior vertebral line disruption at L1
   • disruption = fracture
4. loss vertebral height at L4 and l1 vertebral body fragments seen projecting anteriorly
5. Vertebral spaces normal
6. Vertebral end plate superior and inferior continuity.
   • superior end plate of l1 disrupted
7. Posterior elements
   • pedicles:widened distance normal
   • spinous processes: increased distance = flexion distraction injury

Pathology= Flexion distraction injury lumbar

Question 9

Identify pathology picture 47 in trauma section

Answer 9

•Sagittal View MRI scan of spine of Mr X on the date of y
. Alignment: anterior and posterior Vertebral lines disrupted and neither in kyphosis nor lordosis
• loss of vertebral height seen between 2 vertebrae therefore a fracture is present
• vertebral space increased
• vertebral end plates not continuous
• multiple fragments of the vertebral body seen
• spinal cord compression seen

Pathology: bifacetal Fracture dislocation and spinal cord compression

Question 10

Identify pathology picture 48 in trauma section

Answer 10

Fracture dislocation of the Thoracolumbar spine

• anterior and posterior vertebral line disruption

Question 11

Identify and classify pathology picture 55 in trauma section

Answer 11

Tile pelvic fracture type c: rotationally and vertically unstable

Question 12

Identify pathology picture 58 in trauma section

Answer 12

• ap X-ray of Mr x’s knee taken on date y
. Adequacy: adequate . No rotation: slight overlap of lateral tibia and head of fibula. Patella visible in midline. Adequate penetration. would like joint above or below To assess for any other abnormalities.
• effusion: need lateral view to determine.
• bones: no visible fracture. Significant overlap of femur over tibia and fibula, suggesting dislocation
• tibio-femoral alignment: normal, thus no tibial plateau fracture
• patellar tendon: assess on lateral view

pathology: Knee dislocation

Question 13

Identify pathology picture 61 in trauma section

Answer 13

Ant dislocation knee

Question 14

Identify pathology picture 63 in trauma section

Answer 14

• lateral X-ray of Mr x’s left/right knee taken on date y
. Adequacy: adequate . No rotation: fibulae head overlaps tibia and femoral condyles superimposed. Adequate penetration. would like joint above or below To assess for any other abnormalities.
• effusion: suprapatellar recess between prefemoral and suprapatellar fat pad not enlarged, thus no effusion.
• bones: no visible fracture. Posterior dislocation of the knee joint visible.
• tibio-femoral alignment: to be assessed on AP view
• patellar tendon: possible rupture as this distance is longer than the patellar length

pathology: Post knee dislocation

Question 15

Identify pathology picture 50 in trauma section

Answer 15

Lisfranc injury
• tarsometatarsal fracture dislocation with traumatic disruption between articulation of medial
Cuneiform and base of second metatarsal
• discontinuity of line from medial base 2nd metatarsal to medial side of middle cuneiform on ap- diagnostic
• widening interval between 1st and 2nd ray on ap view. May see bony fragment (fleck sign) in 1st metatarsal space representing avulsion of lisfranc ligament from base of 2nd metatarsal - diagnostic.

Question 16

Label picture 56 in trauma section

Answer 16

See picture 57

Question 17

Identify pathology picture 59 in trauma section

Answer 17

Salter Harris type 1 # (physis separation) of the proximal tibia, with minimal shortening, dorsal angulation and 15% apposition

Question 18

Identify pathology picture 68 in trauma section

Answer 18

1. Details: lateral xray of left/right ankle joint of Mr X on date y
2. Adequacy: inadequate.
   Can see distal 1/3 of tibia and fibula
   should also see calcaneus and base of fifth metatarsal.
3. Bones:
   •cortical outlines of tibia disrupted dorsally on metaphysis and intra-articular on epiphysis
   • intra-articular fracture of distal tibia extending from metaphysis through epiphysis. Minimally displaced.
4. Cartilages
   No abnormalities seen
5. Soft tissues
   No swelling or effusion seen

Pathology: Salter Harris #type 4 (through epiphysis to metaphysis) (intra-articular)

Question 19

Identify pathology picture 67 in trauma section

Answer 19

Salter Harris #type 5 (crush) of the distal tibia

Question 20

Identify pathology picture 66 in trauma section

Answer 20

• This is an ap xray of the left/right elbow of Mr x on date y
• adequacy: inadequate. Wrist joint must be included
• No gross soft tissue swelling visible
• Joint effusion and fat pads: need lateral view to discern.
• bones and alignment: radiocapitellar line disruption, indicating dislocation of radius.
Anterior humeral line to be assessed on lateral view for supracondylar #.
Humerus appears normal.
Ulnar bowing.
• ossification centres by order of appearance (CRITOE): all present up to internal/medial epicondyle, so this child is probably 5 -7 years old

Pathology: Plastic ulna deformity (bowing) with radial head dislocation

Question 21

Identify pathology picture 65 in trauma section

Answer 21

Torus/ buckle # of the distal radius

Question 22

Identify pathology picture 73 in trauma section

Answer 22

1 details: lateral xray of the left / right elbow of Mr x taken on date y
2. Adequacy: inadequate

• need wrist too, to visualise entire ulna and radius
• hourglass/figure of 8 sign present thus no rotation

3. Effusion and soft tissue injury
   None visible, no fat pads
4. Bones:
   • radial head dislocation
   • proximal 1/3 transverse fracture of the ulna with shortening, volar angulation, rotation to be assessed clinically, 10% apposition.
5. Alignment
   • anterior humeral line intact

• radio capitellar linedisplaced thus radial head dislocation

5.ossification centres not present. Adult xray

Pathology: fracture dislocation, Monteggia # type because radial head dislocation with proximal ulnar #

Question 23

Identify pathology picture 74 in trauma section

Answer 23

Galeazzi #
• distal radioulnar joint dislocation
• displaced radial mid shaft fracture with shortening, ulnar angulation , zero apposition

Question 24

Identify pathology picture 76 in trauma section

Answer 24

1.details: ap xray of right hemipelvis of Mr X on date y

2. Adequacy - inadequate
   • not taken from above iliac crests
3. Alignment - can’t comment on only hemipelvis
4. Bones
   • femur: Shenton’s line Disruption- intertrochanteric femur #
   . Pelvic brim continuity
   • obturator foramen continuous
   • Ischium normal
   • ilium can’t comment without full view
   . Pubis normal
   • sacrum can’t comment without full view.
   . Acetabulum: iliopectineal line intact, ilioischial line intact, teardrop sign present
5. Cartilaginous joints
   • acetabular joint: femoral head articulated ,joint space normal 3-5 mm
   • pubic symphysis width can’t comment without full view
   • sacroiliac joint: cant comment

6. Soft tissue and other
• no effusion
•no Periosteal reaction
. No Calcification soft tissues
• no foreign bodies

Pathology: Displaced intertrochanteric femur # that is shortened, angulated, rotation to be assessed clinically, 0% apposition

Question 25

Identify pathology picture 79 in trauma section

Answer 25

Greenstick # of distal radius with minimal change in length, volar angulation and 90% apposition

Question 26

Identify pathology picture 80 in trauma section

Answer 26

Osteogenesis imperfecta

Question 27

Identify pathology picture 81 in trauma section

Answer 27

Supra condylar # completely displaced Gartland type 3 No change in length, slight volar angulation, bayonet apposition. (most common # around elbow)

Question 28

Identify pathology picture 82 in trauma section

Answer 28

Posterior fat pad sign and enlarged elevated anterior fat pad (sail/flag sign) Pathology: occult Supracondylar # Garland type 1 (non-displaced)

Question 29

Identify pathology picture 83 in trauma section

Answer 29

Fracture of the distal 1/3 of the radius and ulna with shortening of the radius, bayonet apposition, and volar angulation.

Question 30

Identify pathology picture 84 in trauma section

Answer 30

Osgood schlattler disease (osteochondrosis-patellar tendon insert onto prox tibia growth plate. Ossicles )

Question 31

Identify pathology picture 85 in trauma section

Answer 31

AcromiOclavicular joint dislocation of the right shoulder with Ac and cc ligament tear • widened gap between acromion and clavicle > 8 mm (ac ligament) • widened gap between clavicle and coracoid 713 mm (coracoclavicular ligament)

Question 32

Identify pathology picture 86 in trauma section

Answer 32

Gartland type 1 Undisplaced supracondylar # | (flag sign) - post fat pad

Question 33

Identify pathology picture 116 in trauma section

Answer 33

1. Details: lateral view of cervical spine of Mr X on date y 2. Adequacy: c1-c7/t1 visible therefore adequate 3. Alignment . Lateral:anterior and posterior longitudinal line and spinous process line intact, . spinolaminar line disrupted at c5 c6 indicating anterior dislocation . Lordosis present 4. Bones • superior cortices of vertebrae c4 and c5 disrupted • odontoid peg normal . Lateral mass of c5 and C6 disrupted • bowtie sign seen at c5 c6: unifacetàl dislocation •facet joints disrupted at c5 c6 - dislocation /subluxation 5. Cartilage / disc spaces normal and symmetrical 6. Soft tissue normal Pathology: Unifacetal dislocation: bow tie sign Anterior dislocation vertebral bodies

Question 34

Identify pathology picture 117 in trauma section (3)

Answer 34

Hangman # c2 (red = fracture) (subluxation, traumatic # of bilateral pars interarticularis of C2) Disruption anterior line, pre-vertebral soft tissue swelling (orange) Anterior dislocation c2 (blue)

Question 35

Approach to Knee X-ray? (8)

Answer 35

1. Details: patient, date, view, side 2. Adequacy: • AP centered on joint space with slight overlap lateral tibia and head fibula. Patella in midline. • Lateral fibulae head overlap tibia and femoral condyles superimposed. • Ideally 2 joints with 2 views. 3. effusion and soft tissues: suprapatellar recess between prefemoral and suprapatellar fat pad should be <5mm. Effusion indicate occult fracture or significant ligamentous/cartilaginous injury. 4. bones: fibular head, femur, tibia, patella, tibial plateau, intercondylar eminence 5. Joint articulation: dislocations 6. tibio-femoral alignment: to be assessed on AP view. Line along lateral femoral condyle- tibia should be within 0,5cm of this line otherwise suggest tibial plateau fracture. 7. patellar tendon: Insall-Salvatti ratio, ideally measured with knee flexed at 30 degrees. If patellar tendon length (inferior pole patella to tibial tuberosity ) more/less than 20% of patellar length, indicate patellar tendon rupture. 8. Name pathology

Question 36

Approach to Elbow X-rays? (5)

Answer 36

1 details: name, date, side, view 2. Adequacy: • preferably 2 joints • lateral: check for rotation with hourglass/figure of 8 sign (normal) 3. Effusion and soft tissue injury • anterior fat pad: small is normal but large (sail sign) = intra-articular injury • posterior fat pads: always abnormal = fracture occult 5. Bones: obvious fractures humerus, radius, ulna. 4. Alignment • anterior humeral line: down anterior border humerus on lat view, should go through middle 1/3 of capitellum. Displacement = fracture (usually supracondylar) • radio capitellar line: through middle of prox end radius, should bisect capitellum in both views. Displace = radial head dislocation • angulation radial head- fracture 5.ossification centres: CRITOE in order of appearance by age- capitellum (1), radial head (3), internal/medial epicondyle (5), trochlea (7), olecranon (9), external epicondyle (11)

Question 37

Approach to Thoracolumbar X-rays? (7)

Answer 37

1. Details: name, date, view, 2. Adequacy • lumbar: t11/t12 - sacrum with vertebral bodies, facet joints, pedicles and transverse processes clearly visible. On ap, spinous processes central and transverse processes equal distance. • thoracic: c7/t1 - t12/l1 with all aspects clearly visible. 3. Alignment . Ap: vertebral bodies and spinous processes aligned • lateral: alignment vertebral bodies anterior (disrupted with burst # ) and posterior lines • disruption = fracture 4 loss vertebral height = compression fracture associated with osteoporosis or burst # 5. Vertebral spaces • should gradually increase from top to bottom • narrow = spondylosis 6. Vertebral end plate superior and inferior continuity. • multiple fragments = burst # • end plate sclerosis = spondylosis ( also osteophytes formation) 7. Posterior elements • pedicles:widened distance = burst fracture • laminae • spinous processes: increased distance = flexion distraction injury

Question 38

Approach to pelvic X-rays? (6)

Answer 38

D ABCs 1.details: name, date, view 2. Adequacy • above iliac crests to 1/3 down femoral shaft •Penetration ``` 3. Alignment • coccyx tip and pubic symphysis in midline • Shenton's line • iliopectineal line •Ilioischial line • roof and medial wall acetabulum • anterior wall acetabulum • posterior wall acetabulum ``` 4. Bones • femur: Shenton's line along medial femoral neck and inferior edge of superior pubic ramus. (Disruption- neck femur #adults, DDH children) . Pelvic brim continuity for # -if see one #, look for the other. Rarely only in 1 place. • obturator foramen • Ischium • ilium . Pubis • sacrum . Acetabulum: iliopectineal line (disruption = anterior column fracture), ilioischial line (post column), teardrop sign (displace = occult acetabular #) 5. Cartilaginous joints • acetabular joint: location femoral head (dislocation), joint space typically 3-5 mm (reduced = osteoarthritis ) • pubic symphysis width (wide =pelvic ring fracture or diastasis) • sacroiliac joint: joint space 2-4 MM, joint end plates smooth and regular (wide = pelvic ring # or sacroiliitis ) 6. Soft tissue and other • effusion: hyperdensity, fluid level ( eg inflammatory joint disease) •Periosteal reaction:nonspecific radiographic finding that indicates periosteal irritation eg healing fracture, bone tumour . Calcification soft tissues eg phleboliths, panniculitis, atherosclerotic vascular calcifications ) • foreign bodies eg total hip replacement

Question 39

approach to C spine xray? (6)

Answer 39

DabCs 1. Details: name, date, view 2. Adequacy: c1-c7/t1 must be visible 3. Alignment . Lateral:anterior and posterior longitudinal line, spinolaminar line, spinous process line • ap: 2 lateral lines down each side of vertebral bodies and spinous process line • odontoid view: alignment of lateral masses of c1 and c2, alignment of odontoid peg with lateral masses of c2 . Lordosis ``` 4. Bones • cortices of vertebrae • odontoid peg . Lateral mass of c2 • examine each vertebra for fracture/collapse/avulsion • parallel facet joints ``` 5. Cartilage / disc spaces • loss height, herniation, symmetry etc 6. Soft tissue • prevertebral soft tissue line on lateral view: widening = prevertebral haematoma with fracture suspicion. Above c4 no larger than 1/3 of adjacent vertebral body (<7mm); from c4 onwards no larger than width of one whole vertebral body (<22mm)

Question 40

Xray findings of osteomyelitis? (5)

Answer 40

May be normal first 10 days! Technetium bone scan most sensitive. * Soft tissue swelling - early sign (and suppuration) * osteolysis / lytic bone distruction/necrosis/ osteopenia/ sequestra ! (Trapped necrotic bone) after 2 weeks * new periosteal bone formation / thickening/ periosteal reactions !, especially in response to #, /involucrum after 1 week - appear “hazy”/ “moth eaten” appearance! * metaphyseal rarefaction (reduction in bone density) after 2 weeks- late sign * Brodie ‘s abscess! (Chronic) * subperiosteal abscess! * pot puffy tumour * sclerosing osteomyelitis of Garre * endosteal scalloping * Cloaca! (Chronic, cortical defect that drains pus from medulla to surrounding soft tissues)

Question 41

What does disruption Shenton line indicate?

Answer 41

Adults: neck of femur # Paediatrics: DDH

Question 42

What does disruption Illopectineal line indicate?

Answer 42

Anterior column acetabular #

Question 43

What does disruption Ilioischial line indicate?

Answer 43

Posterior column acetabular #

Question 44

What does disruption Of teardrop sign indicate?

Answer 44

Occult acetabular #

Question 45

What does widened interpedicle distance indicate on xray?

Answer 45

Burst #

Question 46

What does widened Spinous process distance indicate on xray?

Answer 46

Flexion distraction injury

Question 47

Identify pathology picture 18

Answer 47

Peri- implant fracture of the middle 1/3 of the femur with shortening, angulation and 20% apposition. Rotation to be assessed clinically.

Question 48

Identify Pathology picture 19

Answer 48

Minimally displaced Peri- implant fracture of the femoral midshaft extending distally.

Question 49

Name 3 radiological signs of slipped upper femoral epiphysis

Answer 49

* Trethowan's sign on lateral view = Klein's line displaced: should go from superior aspect femoral neck and intersect epiphysis of femoral head.! * epiphysis has "woolly" appearance * posterior and medial slip of epiphysis

Question 50

Name 3 radiological signs septic arthritis

Answer 50

* joint space widening * vacuum phenomenon- collections of gas * soft tissue swelling

Question 51

Approach to ankle X-ray? (5)

Answer 51

1. Details: name, date, view, side 2. Adequacy: • should see distal 1/3 of tibia and fibula • mortise views: should also see talus . Lat view: should also see calcaneus and base of fifth metatarsal. 3. Bones: • trace cortical outlines in all views of all bones • mortise views: trace mortise and talar dome surface • lateral view: assess medial, lateral and posterior malleoili, calcaneus, base of 5th metatarsal • internal architecture bone eg thin cortex and increased lucency= osteopenia or osteoporosis 4. Cartilages • mortise: joint space loss (osteoarthritis), widening (fracture or dislocation) • medial clear space (mortise): widest distance between medial border talar bone and lateral border medial malleolus should be = to superior clear space (between articular surfaces of tibia and talus). Widening (lateral talar shift) = syndesmosis disruption therefore joint instability • tibiofibular overlap loss (syndesmosis injury) • joint widening with no obvious #on this xray may indicate more proximal #eg maisonneuve # 5. Soft tissues • swelling, effusion

Question 52

How describe angulation of fracture on XR?

Answer 52

According to distal segment - volar/dorsal/ulnar etc angulation OR according to apex (point of intersection between distal and prox segment) eg apex dorsal displacement

Question 53

What is bayonet apposition?

Answer 53

2 bone fragments aligned side-by-side rather than end-to- end.

Question 54

How interpret shoulder xrays?

Answer 54

1. Details: name, date, view, side 2. Adequacy: 2 views, 2 sides 3. Alignment • ap: glenohumeral joint- glenoid fossa (socket) should be visible as concavity medial to humeral head - ant dislocation = humeral head inferomedial to glenoid; disruption Maloney's line , increased subacromial space, - post dislocation - glenohumeral joint widened and numeral head has "light bulb" appearance due to forced internal rotation - Ac joint dislocation: widened gap between acromion and clavicle >8mm (pathology Ac lig) or between clavicle and coracoid process >13mm (coracoclavicular ligament) - acromiohumeral distance <7mm = supraspinatus tear >12 mm = joint widening eg effusion • scapular y/ lateral view: humeral head on top of glenoid fossa with coracoid process ant to it, Mercedes Benz sign -Ant dislocation: head anteroinferior to glenoid fossa and coracoid process - post dislocation: humeral head posterior to glenoid fossa • subacromial space 8-14 MM.! . Maloney's line gothic /arch / Shenton line of shoulder intact - ap . from lateral border scapula towards glenoid neck and along medial border humerus 4. Bones - follow cortex • ribs • humerus • clavicle - most common paediatric shoulder injury, especially midshaft. • scapula -fracture here indicate significant trauma 5. Soft tissue • effusion • lungs

Question 55

How interpret wrist xray?

Answer 55

1. Details: name, date, view, side 2. Adequacy: include distal radius and ulna with no overlap 3. Alignment ap • smooth distal radial contour (irreg = # ) • distal radial articular surface should cup carpals • radial inclination: from distal radius to perpendicular shaft, normal 21-25° (>25= #) • radial length/height: between 2 lines drawn perpendicular to long axis radius from apex radial styloid and level of ulnar aspect of particular surface, normal 8-14 MM. Loss = impacted radial # • Gilula's /carpal arcs (disruption = # or ligament injury) Alignment lateral • long axis of radius, lunate, capitate and third metacarpal should align (Apple, cup, saucer) (empty cup- perilunate dislocate ) • palmar/volar cortex of pisiform should lie between scaphoid and capitate • radius surfaces smooth • volar tilt of 10-25° between line along distal radial articular surfaces and line perpendicular to longitudinal axis of radial shaft. ``` 3. Bones - margin and trabecular pattern • radius • ulna, ulnar styloid • carpals esp scaphoid and prox row - most frequently injured and risk AVN • metacarpals ``` 4. Cartilaginous Articulation - normal joint spaces • intercarpal and carpometacarpal should be 1-2mm 5-soft tissue

Question 56

Label picture 23

Answer 56

See picture 24

Question 57

Label picture 25 and name view

Answer 57

See picture 26

Question 58

Label picture 27 and name view

Answer 58

See picture 28

Question 59

Label picture 29 indicating numeral head, glenoid fossa, acromial process, distal clavide, coracoid process and name view

Answer 59

See picture 30

Question 60

Label picture 31 indicating numeral head, glenoid fossa, acromial process, distal clavide, coracoid process and name view

Answer 60

See picture 32

Question 61

Label picture 33

Answer 61

See picture 34

Question 62

How assess alignment on Pa view of wrist? How draw?

Answer 62

See picture 35 - Gilula's carpal arcs- disruption = underlying # or ligament injury.

Question 63

Label picture 36

Answer 63

See picture 37

Question 64

Label picture 38 and name view

Answer 64

See picture 39

Question 65

Radiological findings osteosarcoma?

Answer 65

* Variable: hazy osteolytic areas with unusually dense osteoblastic areas * poorly defined tumour margins * sunburst effect : cortex breached and tumour spread into adjacent tissues -streaks of new bone radiating out from cortex * Codman's triangle: where tumour emerges from cortex, reactive new bone forms in angle between periosteum and cortex.

Question 66

Describe the Mercedes Benz sign

Answer 66

* Sign on lateral view of shoulder indicating shoulder dislocation of disrupted * components = acromion(posterior), coracoid (anterior), blade of scapula (inferior), glenoid, (central), humeral head * if humeral head under coracoid and on ribs = ant dislocation * if under acromion = posterior

Question 67

! Xray signs of ant shoulder dislocation? (4)

Answer 67

AP • humeral head inferomedial to glenoid • disruption Maloney's / gothic arch/shenton line of shoulder • widened subacromial space >14 mm Lateral • head anteroinferior to coracoid process and glenoid fossa, disrupting Mercedes Benz sign

Question 68

! Name 5 signs lisfranc injury on xray

Answer 68

5 critical signs: • discontinuity of line from medial base 2nd metatarsal to medial side of middle cuneiform on ap- diagnostic (and 1st mt with medial cuneiform) • widening interval between 1st and 2nd ray on ap view. May see bony fragment (fleck sign)! in 1st metatarsal space representing avulsion of lisfranc ligament from base of 2nd metatarsal - diagnostic. • dorsal displacement of proximal base of 1st or 2nd metatarsal on lateral view • medial side of base of 4th metatarsal doesn't line up with medial side cuboid on oblique view • disruption of medial column line (line tangential to medial aspect of navicular and medial cuneiform) on oblique view

Question 69

Identify pathology picture 40

Answer 69

Multiple myeloma | • multiple "punched out" well demarcated lesions

Question 70

Identify pathology picture 41

Answer 70

Multiple myeloma • multiple "punched out" well demarcated lesions • no surrounding sclerosis • marked bone expansion

Question 71

Identify pathology picture 42

Answer 71

Multiple myeloma • multiple "punched out" well demarcated lesions • no surrounding sclerosis

Question 72

! Name 5 radiological signs of osteoarthritis

Answer 72

``` LOSS • Loss of Joint space (narrowing) • osteophytes • subchondral sclerosis • subchondral cysts • eburnation of bone -ivory-like reaction occurring at site of cartilage erosion. ```

Question 73

Approach to foot xrays?

Answer 73

D ABCs Details: name, date, time, view, area, side, skeletal maturity Adequacy 3 views • dorsal plantar view • oblique view Lateral Alignment • second metatarsal align with intermediate cuneiform on dp /ap view (disrupt = lisfranc ) • third metatarsal align with lat cuneiform on oblique view (disrupt = lisfranc ) • fourth metatarsal medial base align with medial side cuboid on oblique • medial column line - tangential to medial navicular to medial cuneform Bones - bohler angle: angle between line from highest point of ant process of calcaneus to highest point of post facet, plus line tangential to sup edge of tuberosity. If angle <20 = calcaneal fracture. Cartilage • widening between first and second metatarsal = lisfranc Soft tissue

Question 74

XR feature calcaneal #?

Answer 74

Lateral: loss Bohler angle. Line drawn from ant process calcaneus to peak of post articular surface, second line from peak post articular surface to peak post tuberosity. N= 25-40.

Question 75

Radiographic findings of Tb spine? (5)

Answer 75

Early infection: involvement of ant vertebral body with sparing of disc space ``` late: • disc space destruction • lucency (black) and compression adjacent vertebral bodies • severe kyphosis (gibbus) • buckling collapse ```

Question 76

Label picture 43

Answer 76

See picture 44

Question 77

Label picture 45

Answer 77

See picture 46

Question 78

Label picture 47

Answer 78

See picture 48

Question 79

Label picture 49

Answer 79

See picture 50

Question 80

Identify pathology picture 119 trauma section

Answer 80

• Loss alignment lateral masses of C 1 C 2 . Widened space between peg and lateral masses c1 •thus subluxation

Question 81

Identify pathology picture 120 trauma section.

Answer 81

* Loss alignment posterior vertebral and spinolaminar lines. * perched facets and dislocation injury of c5 c6 * displaced body > 50% body width thus bifacital dislocation * widening pre-vertebral soft tissue line > 22 mm

Question 82

Identify pathology picture 121 trauma section.

Answer 82

* Odontoid peg # * cortical ring c 2 incomplete * Break anterior line at C 1

Question 83

Radiographic findings of lunate dislocation? (6)

Answer 83

Pa • Break in Gilula's arc • lunate and capitate overlap • "piece of pie" sign due to triangular appearance of lunate from palmar rotation due to dorsal force of carpus Lateral • loss saucer cup and apple sign. Aka loss colinearity of radius, lunate, capitate. • sl angle >70° • spilled teacup sign

Question 84

Name 2 xr features of subcapital/ neck of femur #

Answer 84

* Disruption Shenton's line | * altered neck-shaft angle (normal 130 )

Question 85

Radiographic findings osteosarcoma? (4)

Answer 85

* Characteristic blastic and destructive lesion:sunburst or hair on end pattern of matrix mineralisation (spicule formation, tumour extension into periosteum) * periostea reaction (Codman's triangle) * large soft tissue shadow (mass) * destructive lesion in metaphysis may cross epiphyseal plate

Question 86

Treatment osteosarcoma?

Answer 86

* complete resection - limb salvage, rarely amputation * neo-adjuvant chemo * bone scan and CT chest to rule out metastasis

Question 87

Which joints require 3 views? (4)

Answer 87

* Ankle (ap, lat, mortise) * neck (AP, lat, odontoid) * Wrist. (ap, lat, oblique) * foot (ap, lat, oblique)

Question 88

How is mortise view of the ankle taken?

Answer 88

Modified ap view with ankle in 10-20° internal rotation so that medial and lateral malleoli are in same horizontal plane

Question 89

Identify pathology picture 134 in trauma section

Answer 89

Vertebral body fracture of C7 | • anterior vertebral line disruption

Question 90

Identify pathology picture 135 in trauma section

Answer 90

* C2 body # * misalignment lateral borders c1 and c2. * difference in space between odontoid process and lateral masses c2

Question 91

Identify pathology picture 131 in trauma section

Answer 91

Right superior Pubic ramus # | • disruption illopectineal line

Question 92

Identify pathology picture 133 in trauma section

Answer 92

Pubic rami and ischium # • disruption obturator foramen • disruption Shenton's line • disruption ilioischial line

Question 93

Identify pathology picture 136 in trauma section

Answer 93

Open book # • pubic symphysis and sacroiliac joint separation • left sided pelvic bone rotation causing disruption of all major lines

Question 94

Identify pathology picture 128 in trauma section

Answer 94

Acetabular # dislocation of roof | • iliopectineal line disruption

Question 95

Is picture 138 in trauma section an adequate xray?

Answer 95

No. • can't see C7 (must see until t1) • neck too extended, hiding c1.

Question 96

Identify pathology and classify picture 141 in trauma section

Answer 96

Right femoral neck # • disruption Shenton's line • garden type 4: complete displacement, complete fractures, varus alignment,

Question 97

Identify pathology picture 142 trauma section

Answer 97

Anteroinferior hip dislocation (rare) • disruption Shenton's line • loss congruent femoral head with acetabulum • femoral head appears larger than contralateral head thus anterior • femoral head inferomedial to acetabulum thus anterior

Question 98

Identify pathology picture 143 trauma section

Answer 98

Posterior hip dislocation (most common) • Loss congruence femoral head with acetabulum • Shenton's line disruption • femoral head appear smaller than contralateral femoral head thus post • femoral head superimposes roof acetabulum thus post • decreased visualisation lesser trochanter due to internal rotation of femur

Question 99

Identify pathology picture 52

Answer 99

``` Osteoarthritis of the hip joint • loss joint space • osteophytes around femoral head • subchondral sclerosis • subchondral cysts (appear dark) ```

Question 100

Identify pathology picture 53

Answer 100

Occult supracondylar fracture: Gartland type 1 | • posterior fat pad or sail sign.

Question 101

Label picture 54

Answer 101

See picture 55

Question 102

Label picture 56

Answer 102

``` Left = normal Middle = femoral anteversion Right = femoral retroversion ```

Question 103

Identify pathology picture 57

Answer 103

Anterior shoulder dislocation (most common) • humeral head lie medial and inferior to glenoid fossa on ap (left) • humeral head anterior and inferior to glenoid fossa, over ribs on lat view (right) • humeral head inferior to coracoid process • disruption of Mercedes Benz sign on lat view

Question 104

Identify pathology picture 58

Answer 104

Posterior shoulder dislocation • light bulb sign • glenohumeral joint widened

Question 105

Identify pathology picture 65

Answer 105

Supracondylar # Gartland type 3 with shortening, no apposition, anterior angulation Post fat pad sign

Question 106

Label picture 67

Answer 106

See picture 68

Question 107

Classify and label picture 69

Answer 107

Ao classification A: compression injuries (shortening) B: distraction injuries (lengthening) C: torsional injuries (rotation)

Question 108

Identify pathology picture 70

Answer 108

Salter Harris type 3 #of radius: epiphysis extending into physis intra-articular Ulnar styloid avulsion # Distal radio-ulnar joint dislocation

Question 109

Identify pathology picture 71

Answer 109

Bottom right = radial head dislocation | Disruption of radiocapitellar line ( through middle radius, should bisect capitellum in lat and AP)

Question 110

Identify line in picture 72

Answer 110

Anterior humeral line - should go through middle 1/3 capitellum Displacement =#

Question 111

Identify pathology picture 73

Answer 111

Supracondylar # Gartland 1 minimally displaced • disruption ant humeral line (doesn't pass through middle 1/3 capitellum) • post fat pad sign • condyles displaced dorsally