Slide Exam Prep Flashcards
DISH main radiographic features
At least 4 contiguous vert. bodies with marginal syndesmophytes
Normal: disc height, subchondral bone, facets
NO HVLA. Refer for medical management (medication?)
Ankylosing Spondylitis main radiographic features
Romanus lesions (corner erosion)
Shiny corner sign
B/L symmetrical sacroilitis (bead sign, sclerosis (+/- star sign), ghost sign (complete fusion))
BL symmetrical marginal syndesmophytes (fine, multilevel, bamboo spine, osteoporosis, carrot stick fracture
Dagger sign, trolley track sign
NO HVLA. Refer to GP for medical management,
Psoriatic Arthritis
Non-marginal asymmetrical syndesmophytes:
Increased ADI
U/L or B/L Asymmetrical sacroilitis
** Same radiographic findings as Reactive Arthritis in the spine **
NO SMT
Reactive Arthritis
** Same radiographic findings as Psoriatic Arthritis in spine **
+finger signs for next slide exam
NO SMT (double check?)
Osteitis Condensans Ilii
Isolated to SIJ, B/L triangle sclerosis in ilium subchondral bone (only ilium side)
NO erosions or joint space change
CAN HVLA but not likely to be useful
Osteitis Pubis
- erosions, motheaten, wider pubic symphysis
- local osteoporosis
** Can’t tell appart from Infection off radiograph only **
No SMT?
CPPD
Small linear horizontal calcification in disc at multiple levels
*meniscus calcification
Can SMT
HADD
Small calcification anterior to C2
Calcification of longus colli muscle
Can SMT?
Hypertrophic Osteoarthropathy
B/L symmetrical long bone periostitis
Presents as: digital clubbing, often secondary to cardiopulmonary, GIT, endocrine, hematologic, and inflammatory conditions
No HVLA until primary condition not determined. Refer to GP for blood tests
Differentials for B/L symmetrical sacroiliitis
AS
Enteropathic Arthritis
Osteitis Condensans Ilii
Differential for U/L sacroiliitis
Rheumatoid A.
Infection
DJD
Also Reactive / PA
Differential for B/L asymmetrical sacroiliitis
PA / Reactive
Differential for non-marginal syndesmophytes
- DJD
- DISH
- PA / Reactive
Differential for Marginal syndesmophytes
-Ankylosing spondylitis
More?
Paget’s
Cortical thickening Expansion Coarsened trabeculae Sclerosis / Ivory Pahological fractures
Spine:
-picture frame vertebra
Pelvis:
- lost kohlers teardrop
- thick pubis
- brim sign
- acetabulae protrusio
Skull:
…
Long bones:
- bade of grass defect-pseudofractures
- more..
NO SMT
Differential for Ivory vertebra
Pagets (+ expansion)
Bastic mets
Hodgkins (+ anterior erosio / scallop)
Fibrous Dyslasia
Large geographic lucency with separations, haziness
NO HVLA because weakened bone
Neurofibromatosis
Nerve sheath overgrowth (neoplasm)
-cortex intact
- posterior scalloping
- short angular scoliosis
- kyphosis
- IVF very large (means its in the IVF)
- scalloped ribs
-asymmetrically elongated phalanges
No SMT
Differential for posterior scalloping
Neurofibromatosis Marfans Ehlers Danlos Achondroplasia Osteogenesis imperfecta
Differential for lucent benign lesions
Haemangiona Non-ossifying fibroma, Fibrocortical defect SBC, ABC, GCT Osteobastoma, Chondroblastoma Enchondroma, Ollier’s disease
Differential for sclerotic malignant lesion
Osteosarcoma
-Parosteal osteosarcoma
Metastasis
Differential for mixed sclerotic and lucent malignant lesion
Osteosarcoma
Mets
Differential for lucent malignant lesion
Plasmacytoma Chordoma Ewing’s sarcoma Malignant GCT Chondrosarcoma Fibrosarcoma Non-Hodgkins Lymphoma Hodgkins Lymphoma Multiple Myeloma Mets
Gardner’s Syndrome
Multiple osteomas (skull + hands and feet)
Can HVLA. Refer to investigate for systemic signs (epidermal cysts, colonic polyps)
Hereditary Multiple Exostoses
Multiple osteochondromas (bony growths off the cortex of long bones)
Could HVLA but with caution as they can fracture.
Osteoblastoma
Sclerotic periosteal rim around lucent nidus >25mm diameter, expansive, thins cortex
-posterior elements of spine, C1 SP
DDx: Osteoid osteoma (smaller), ABC (more expansion + no sclerotic rim)
NO HVLA because weakened bone fracture risk
Ollier’s Disease
Multiple enchondromas
Marfucci’s Syndrome
Very rare
Chondroblastoma
One of the few tumours that are in the epiphysis
Parosteal Osteosarcoma
Lobulated juxtacortical sessile mass, lytic portions
DDx: osteoma (much smoother and less messy)
Plasmacytoma
Geographic lucent soap bubbly, expansive Fades away bone areas (erased) Targets: mandible, ilium, vertebra, ribs, prox femur, scapula, sacrum DDx: Chordoma, Malignant GCT REFER because malignant
Chordoma
Invades surrounding STs, large, crosses disc space
85% sacrococcygeal or spheno-occipital
Malignant
DDx: Infection
Hodgkins Lymphoma
-vertebral body
- anterior scalloping of vert body
- ivory vertebra
DDx:
- Multiple myeloma
- Pagets
Jefferson’s fracture
APOM: lateral masses shift past articular processes C2
-say transverse ligament rupture if masses displaced >7mm
Hangman’s fracture
- B/L pedicle fracture
- Lateral view
-hyperextension injury
Differential for increased ADI
- agenesis dens
- agenesis posterior arch
- RA
- PA
- trauma
- Downs
- Marfans
- Ehllers Danlos
- Morquio’s
C1 posterior arch fracture
(study some images)
Pillar fracture
Wider, altered shape
study some images
Posterior ponticle
Bridging C1 poaterior arch and occiput
Can SMT
Uncinate fracture
- tiny triangle on AP view
- rare
Differential for blurry C1 SP
Malignant:
- chordoma
- plasmacytoma
- lytic mets
Benign
- osteoblastoma
- ABC
- GCT
Differential for missing pedicle on AP view
Lytic mets
Osteobastoma
Chordoma
*multiple myeloma spares the pedicle
Differential for vertebral body destruction
Disc space intact
Lytic mets
Chordoma
Plasmacytoma
Differential for posterior elements destruction
Infection
Lytic mets
Differential for triangular ossific density anterior to the disc space
- Limbic bone (smaller than defect)
- Intercalary bone (in front and no defect)
- Teardrop fracture (exact missing piece)
- Ring epiphysis (widespread)
- Compression fracture (ish)
Differential for bony fragment posterior to C7
- clay shovelers fracture perfect match and displaced a bit)
- persistent apophysis (smaller)
- nuchal bone (vertical)
Agensis dens
- can’t see odontoid
- triangular anterior arch + bigger + more sclerotic
TVP fracture
C7 TVP
Lumbar TVP
Sacral fractures
- usually also pelvic fractures
- not on SLIDE exam 1?
Differential for single non-marginal syndesmophyte
Highly likely Psoriatic arthritis
DJD
DISH
Picture frame vertebra
Pagets
Sandwich vertebrae
Bone-in bone look
Osteopetrosis
Rugger Jersey spine
Hyperparathyroidism
What are the elements in the description of a scoliosis?
- Convex side
- Start and end
- Cobb angle
- Apex
- Rotation: grade, side, span
- Skeletal maturity: Risser’s or epyphysis visible
- Obvious cause
- Secondary consequences (DJD)
Grade rotation of a scoliosis
1+ pedicle bit to midline (other overlaps with edge of vert)
2+ pedicle 2/3 midline (other barely visible)
3+ pedible midline (other not visible)
4+ pedicle past midline (other not visible)
Risser Sign grading
- 25% grown
- 50%
- 75%
- 100% visible
- Fused to ilium (closed)
Where is most degenerative spondylolysthesis? And Isthmic ? Dysplastic?
DJD spondy : L4
Pars fracture: L5
Congenital: L5
C1 posterior arch agenesis
C2 megaspinous, C1 anterior arch hypertrophy
DDx: occipitalisation
NO HVLA until proven stable. Refer for flexion extension views
Agenesis pedicle
- winking owl
- sclerotic C/L pedicle
DDx:
- Lytic mets
- rotation
Yes SMT. Stable
Agenesis articular process
Check images
Yes SMT. Stable
Hemivertebra
Check images
-short angular scoliosis
NO SMT
Caudal Regression Syndrome
- sacral agenesis
- 2 lia articulate
Os odontoideum
- lucent gap
- failure of fusion of dens to body
- instable
DDx:
- mach effect
- fracture
NO SMT. Unstable
Ossiculum Terminale
-lucent gap at tip of dens
Yes SMT. Insignificant
Spondyloschisis
SBO at C1
APOM: follow cortical lines of lamina
Lateral: no spinolamina junction line
DDx bifid vertebra
No HVLA because instability
Clasp Knife deformity
- SBO at S1
- long L5 SP
Butterfly Vertebra
- AP
- triangular endplate lines
Yes SMT. Insignificant
Occipital vertebrae
Epitransverse
Paracondylar
Paramastoid
*check images
NO SMT
Occipitalisation
- C1 fused to occiput
- atlantoaxial instability
NO SMT
Congenital block vertebrae
- wasp waist
- posterior elements maybe fused too
Can maybe SMT
Acquired block vertebrae
Barrel shape
DDx: infection, DJD, malignancy, surgical
Lumbosacral transational segment
Can SMT but different mechanics
Basilar impression
-dens passes McGregors line >45mm
DDx:
- occipitalisation
- spondyloschisis
- abnormal dens or atlas
- klippel-fail
- osetomalacia, tumour…
NO SMT
Eagles syndrome
- stylohyoid ligaments calcified
- looks like phalanx bones
NO SMT
Facet Tropism
Asymmetrical facet orientation
DDx: rotation
Can SMT. Changes biomechanics
Schmorl’s Nodes
-clear corticated circular depression
DDx:
- compression fracture
- nuchal impression
Can SMT. Insignificant
Nuclear Impressions
- smooth indentation in endplate
- AP: cupids bow
DDs: lateral flexion
Can SMT. Insignificant
Venous Channel of Hahn
-horizontal sclerosis in anterior middle of vertebra
Can SMT. Insignificant
Omovertebral Bone
Bone from cervical spine to scapula
SMT??
Klippel-Feil Syndrome
- Block vertebrae
- Basilar impression
- Scoliosis
- Sprengel’s deformity
Presents as: short neck, limited neck mobility
NO Cervical HVLA due to possible instability
Achondropplasia
- bullet-nose vertebrae
- posterior scalloping
- short pedicle (stenosis)
- large spinal curves
- basilar impression
- ping pong paddle ilium
NO SMT
Cleidocranial Dysplasia
- small or no clavicle
- small scap
- biconvex vertebrae
- SBO
- hemivertebrae
- large curves
- small pelvis
- small dens
NO SMT
Spondyloepiphyseal Dysplasia
Widespread platyspondyly, bulbous vertebrae, large spinal curves, short ilium, widespread skeletal changes
NO cervical HVLA because of atlanto-axial instability. Can treat else wear. Refer to examine for associated systemic dysfunctions.
Holr-Oram Syndrome
- heart hand syndrome
- sprengles deformity
+ more
No SMT?
Fibrodysplasia Ossificans Progressiva
- striate muscle calcification
- torticolis
- osteomalacia
- pathological fractures
NO manual therapy at all
Marfan’s Syndrome
- tall vertebra
- posterior scalloping
- thin cortex
- scoliosis
NO SMT because lax dense?
Metaphyseal Dysplasia
- widespread platyspondyly
- erlenmeyer flask deformity
No SMT?
Nai-Patella syndrome
Not realy spine
Ehlers Danlos Syndrome
- widespread platyspondyly
- posterior scalloping
- large spinal curves
- early DJD
NO SMT. Weak bones
Hurler’s Syndrome
- short vertebrae
- round vertebrae
- small dens
- paddle ribs
- flair ilia
- osteoporosis
NO SMT
Morquio’s Syndrome
- widespread platyspondyly
- centrall beaking vertebral bodies
- large curves
-small dens
NO SMT
Osteogenesis Imperfecta
Biconcave vertebrae Platyspondyly Osteoporosis Multiple fractures Large spinal curves
Presents with: blue sclerae, multiple frequent fractures with little trauma, bone deformities
NO HVLA
Melorheostosis
- hyperostosis under periosteum along side of long bones
- candle wax dripping
Can SMT. Insignificant unless huge
Osteopathia Striata
- B/L
- vertical linear opacities from metaphysis to diaphysis
Cinicaly insignificant
Osteopoikilosis
- widespread small round opacities
- B/L, symmetrical, uniform
DDx:
-mets
Clinicaly insignificant
Osteopetrosis
-dense brittle bones
- generalised sclerosis
- bone within bone / sandwich vertebrae
-erlenmeyer flask deformity
NO SMT
Differential of widespread platyspondyly
Multiple myeloma
Osteoporosis
Spondyloepiphyseal dysplasia
Meta[hyseal dysplasia
Ehlers Danlos
Morquio’s
Differential for posterior scalloping
Single:
Neurofibromatosis
\+?? Widespread: Achondroplasia Ehers Danlos Marfans
Differential for widespread bullet nose vertebrae
Achondroplasia
Spondyloepiphyseal dysplasia
Hurlers disease
What are the elements of a radiographic description of a fracture?
- Location (in body)
- Orientation (horz, vert obli)
- List cortices broken
- Alignment (distal frag to prox)
- Apposition (good, partial, none)
- Rotation
- Joint space and ST involvement
Compression fracture
- step defect
- wedge deformity
- linear zone of condensation
- lucent line
- paraspinal swelling
- compression or pathalogical
- new or old
Burst fracture
Like compression fracture but more central and increase AP diameter
Odontoid fracture
Type 1:
- oblique tip
- stable
Type 2:
-dense base
Type 3:
-odontoid onto body
2 and 3 not stable
Chance fracture
- horizontal splitting of spine and neural arch
- L1 to 3
Degenerative Joint Disease
Osteophytes, subchondral sclerosis and cysts
Facets: Bubble like (AP view), IVF narrowing (Oblique view)
IVD: decreased height, vacuum phenomenon, intercalary bone
Uncinate: cat ears, pseudofractures (Lateral view)
Can HVLA (unless suspect instability), no referral needed (unless suspect instability)
Rheumatoid arthritis
- dens erosion
- > ADI
- stepladder spondylolysthesis
NO SMT
Differential of irregular endplates
-compression fracture
- nuclear impressions
- schmorls nodes
- lateral flexion
-butterfly vertebrae
+more?
Spondylitis
- starts anterior superior corner of vertebra
- moves up disc into next endplate
- decrease disc space
- ST density in disc space
- ST involvement around
- ankylosis
-can be posterior elements
- paraspinal abscess
- psoas abscess
- paraspinal swelling on AP
Suppurative: less severe
Nonsuppurative:
- TB
- gibbus deformity
NO SMT if active.
Can SMT if old??
Osteomalacia
Lucencies between trabeculae / checkerboard
Double cortex (thin too)
Concave endplates / bowing
Pseudofractures (ribs, pubic and ischial rami, scapula)
Protusio acetabuli (PORT)
NO SMT, refer to GP for blood tests and medical management
Osteoporosis
Pencilled cortices, generalised decrease density, vertical trabecular
Empty box, wedging, vertebra plana, biconcave, hyperkyphosis
DDx:
Multiple myeloma
Post-scheurmans
NO SMT, refer to GP for DEXA and medical management
Hyperparathyroidism
Rugger jersey spine, concave endplates Subperiosteal resorption of outer cortex (frayed look) Blurred cortices **Hallmark** Accentuated trabeculae Salt and pepper / granular skull ST calcifications Clavicle resorption (MSHIRT) Brown tumours: jaw, femur. Pelvis
NO HVLA, refer to GP for medical management
Rickets
-osteomalacia in child
Radiographic features like adult + growth impairment
NO SMT
Features of a benign tumour
Cortex:
- thinning, scalloping, expansion
- thickening
- clear margins
- solid periosteal reaction
GEOGRAPHIC
Features of a malignant bone tumour
- motheaten
- permeative
- cortical destruction
- wide transition zone
-laminated or spiculated periosteal reaction
Osteoma
-skull
Osteoid osteoma
Sclerotic pedicle with acute angle scoliosis around it
Might see the small lucent nidus
Cortical thickening
Presents as: pain relieved by aspirin
DDx: Brodies abscess, stress fracture with healing response
Osteosarcoma
Wide tranzition, fracture, cortex destruction
Sclerotix or mixed
Periosteal reaction, ST involvement
DDx: Ewings sarcoma (kids), Non-Hodgkins (elderly)
Metastasis
- diffuse opacities or densities or both
- assymmetrical, non-uniform
- NO expansion, cortex destruction, periosteal reaction
- accross multiple bones
Enchondroma
- geographic
- bit expansive
- metaphyseal
- endosteal scaloping
-matrix calcification
Haemangioma
-vertical trabeculations
DDx:
-osteoporosis
Nonossifying fibroma
- diametaphyseal
- cortical, eccentric
- oval
- thin cortex
- hazy / smoky
-2-7cm
DDx:
- fibrous dysplasia (bigger)
- osteomyelitis
- brodies abscess
Fibrocortical defect
- diametaphyseal
- cortical /eccentric
- thin cortex
- hazy /smoky
<2cm
Simple Bone Cyst
-fragment sign *Hallmark**
- truncated, central
- septations
- mild expansion
- endosteal scalloping
DDx:
- ABC
- ++??
Aneurysmal Bone Cyst
- extreme expansion
- eggshell cortex
- buttressing
- septation
DDx:
-SBC
Giant Cell Tumour
- up to joint lint *Hallmark**
- epiphysis
DDx:
-Malignant GCT
Malignant GCT
-expansive distal radius
GCT became expansive now
-other place too
Ewings Sarcoma
-kids
- cortical saucer
- diaphyseal
really looks like Osteosarcoma
DDx:
- Osteomyelitis
- Osteosarcoma (ST mass)
- Non-Hodgkins Lymphoma (ST mass)
Non-Hodgkins Lymphoma
-elderly
- permeative / motheaten
- medullary
- patchy
- ST mass
DDx:
- Osteosarcoma
- Ewings (kids)
Chondrosarcoma
- calcific densities
- expansion
- meta/diaphysis
- scalloping
- septations
-ST mass
Fibrosarcoma
-huge ST mass
Multiple Myeloma
- circumscribed
- uniform size multiple circular lytic lesions
- endosteal scalloping
- decerae density
- vertebra plana
DDx:
- Osteoporosis (looks same)
- Lytic Mets
What tumours mostly go to the spine?
Hemangioma
Mets
Multiple Myeloma
Osteoid Osteoma
Sacrum:
- Plasmacytoma
- Chordoma
+more?
Scheurmann’s Disease
At least 3 consecutive vertebra with at least 2 of:
- schmorls nodes
- anterior wedging
- increased AP diameter
- increased kyphosis
- decreased disc height
*must be in a child or teen
Post scheurmans DDx:
-osteoporosis
Differential for hyperlucency in a chest x-ray
- Pneumothorax
- COPD
- Bulla
-mastectomy
Pneumothorax:
- mediastinal shift
- absent lung markings
- shriveled up lung
COPD
- B/L generalised hyperlucent lungs
- big lung size: flat diaphragm, heart lifted off it
- Ephysema
Bulla
- still lung markings
- thin wall of density around
- circular
-can be with emphysema
Differential for hyperdense area on chest x-ray
- Pleural effusion (bottom)
- Atelectasis (uniform, pulls mediastinum)
- Pneumonia (lobe shape, NO mediastinum shift)
- Coin lesion (pulls mediastinum)
- Interstitial fibrosis
- Miiary shadows (TB, Mets, sarcoidosis)
- Pleural plaques
- Mesothelioma
Pleural effusion
- lung base
- meniscus sign
- blunt costophrenic angle
Atelectasis
Uniform:
- lobe shape
- pulls mediastinum
- no lung markings left
Linear:
- 1-3cm above diaphragm
- horizontal
Pneumonia
- lobe shape
- blurry borders
- NO mediastinum shift
- air bronchogram sign: fluid black white circles
DDx for Coin lesions on chest Xray
Mets (spiculated, lobulated, multiple)
Bronchial carcinoma (one mass)
Pleural plaques
DDx for Interstitial fibrosis on a chest xray
Pneumoconiosis
TB
Sarcoidosis, RA, SLE
*Mediastinal shift toward lesion (if U/L)
DDx for Miliary shadows on a chest xray
TB (apical lobe)
Sarcoidosis (middle lobe)
Mets (lower lobe)
(Spotty, similar densities)
No HVLA if Mets (weakened bone=fracture risk), refer to GP for blood tests and medical management
Pleural Plaques
Thickness around lung periphery
Crosses structures (not defined by lobes)
Often B/L
Refer to GP for blood tests and management
Mesothelioma
Lobulated triangular opacity from border of the thoracic cage, pointing towards the lungs
Decreased lung size because it buldges onto lung field
*Refer to GP for CT to accurately stage disease and begin management
Differential for unilateral hilar enlargement
- tumour
- infection
Differential for bilateral hilar enlargement
Sarcoidosis
Mets
Infection
Signs of cardiomegaly on chest Xray
Cardio-thoracic ratio > 1/3
Heart border close to spine on lateral thoracic view
Double contour to the right heart border and splaying of the carina
Abdomina perforation
Air under diaphragm
Inguinal Hernia
Air under inguinal ligament
Hepatomegaly
Liver shadow over ilium and or midline
Bowel obstruction
Air fluid levels
Small intestine visible
Stripes over bowels
Retroperitoneal fluid
-blurred psoas lines
Kidney stones
Stag horn
DDx gallstones
Pancreatic calcification
- spotty pancreas shape
- L and R oblique shape
Gall stones
- sclerotic rim
- grapes
- on the R
Ureteric calculi
larger than phleboliths or uterus fibroids
Splenic artery aneurysm
The only time u see the spnelic artery
Looks like single gallstone (but on the L)
Thoracic/Lumbar trauma indicators that justify an xray
Multiple of the following: female >65, make >75, osteoporosis Hx, chronic corticosteroid use, severe trauma, contusion
Knee trauma indicators that justify an xray
>55 Tender fib head or patella Can't flex to 90 degrees Can't walk at least 4 steps Pain > 7 days
Ankle trauma indicators that justify an xray
Tender distal 6cm of fib or tib, or malleoli
Can’t weight bear
Elderly + malleoli pain
Elderly + swelling
Midfoot trauma indicators that justify an xray
Tender base of 5th metatarsal Tender navicular Can't weight bear Pain >10 days Toe trauma
Hip indicators that justify an xray (non traumatic)
> 4 weeks failed conservative care Hx uninvestigated trauma Lost mobility Acute onset locking Palpable enlarging mass
Shoulder trauma indicators that justify an xray
Serious trauma Shape, mass, deformity Severe mobility loss Epileptic seizure or electric shock First time dislocation
Wrist/hand trauma indicators that justify an xray
Deformity Painful active or passive ROM Tender + oedema Painful grip or supination Pain at snuffbox or on longitudinal thumb compression
Elbow trauma indicators that justify an xray
Inability to fully extend
Forearm pain
Instability
Localised elbow pain
Features that justify a Cervical xray because you suspect spondyloarthropathy
Chronic pain (>3months) + risk factors:
- insidious onset <40yrs
- improves with exercise, NSAIDS
- night pain
- family Hx
- extremity articular symptoms
- systemic symptoms (psoriasis, IBD, uveitis)
Features that justify a Thoracic xray because you suspect a scoliosis
Child or adolescent with:
- positive Adams test
- rib humping
Adult with acute onset or sudden progression of a scoliosis curve
Non-traumatic features that justify a Hip, Knee, Ankle, Foot, Shoulder or Elbow xray
Non change with conservative care >4 weeks Red flags (unrelenting, night pain, not related to movement, fever, unexplained weight loss) Significant activity limitation Swelling, mass, deformity
Differential diagnosis of Acro-osteolysis
Psoriatic arthritis Scleroderma, sarcoidosis Hyperparathyroidism Injury Raynaud's disease Thermal (extreme cold/ heat) (PSHIRT)
