Radiographic Imaging. Standard Cervical Spine Series. Cervical Spine Imaging. Standard Cervical Spine Series. Cervical Spine Imaging 5/2/14

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1 Radiographic Imaging Hector RiveraMelo DC, DACBR Benefits Visualization of significant osseous and articular pathology Risks No safe amount of ionizing radiation Limitations Articular cartilage Soft tissues Early osseous and articular changes Cervical Spine Imaging Standard Cervical Spine Series AP Lower Cervical Lateral Standard radiographic series AP lower cervical AP open mouth Lateral Standard Cervical Spine Series AP Open Mouth Cervical Spine Imaging Accessory radiographic views Obliques Flexion/Extension 1

2 Accessory Cervical Spine Views Anterior Obliques Accessory Cervical Spine Views Extension Flexion Cervical Spine Imaging Common pathology seen on X-rays Osteoarthritis Degenerative disc disease Facet arthrosis Uncovertebral arthrosis DISH Congenital annomalies Hangman s fracture (C2) Unilateral facet dislocation Cervical Spine Imaging Common pathology not seen on X-rays Disc herniations Chiari malformations Facet fractures* C1/2 Mach Effect Gives the appearance of a lucent line. An optical phenomenon from edge enhancement due to lateral inhibition in the retina. Occurs when two objects of similar but different densities overlap. 2

3 C1/2 Odontoid Fracture Question about C2/3 The facets at C2/3 are at a slightly different angle than the rest of the lower cervical spine facets. Pseudofusion appearance is very common. Lack of body involvement is a big clue. Congenital Block Vertebrae C2/3 C2/3 is a common location. Often accompanied by occipitalization of C1. Wasp-waist appearance anteriorly. Posterior element involvement Radiographic Features: Hypertrophy (enlargement) of the articular processes Sclerosis Anterior or posterior translations (advanced) Facet Arthrosis Nuchal Bones and C1 Accessory Ossicle with intercalary bones Nuchal Bones Ossicles within the nuchal ligament. Seen more commonly with increased age. Considered a normal variant. DDx: SP fracture 3

4 Nuchal Bones and C1 Accessory Ossicle with intercalary bones C1 Accessory Ossicle Accessory ossicle of no clinical significance. Considered a normal variant. DDx: HADD of the longus colli ALL calcification Nuchal Bones and C1 Accessory Ossicle with intercalary bones Intercalary Bones Degenerative calcification of the anterior fibers of the intervertebral disc. DDx: Calcification of the ALL (DISH). Atherosclerosis of the carotid arteries. Tear-Drop fracture. Old SP fracture of T1 66 yom with C/S pain AKA: Clay-shoveler s fracture Inferior displacement of fragment Parent/Donor site A stable injury DDx: Ununited growth center. Carotid Artery Atherosclerosis This is a common location for atherosclerosis. Will often look less tube-like and more globular. Will often see accompanying atherosclerosis of other large arteries. Jefferson Fracture Bonus: Tear-Drop Fracture 4

5 Jefferson Fracture Burst fracture of C1. Mechanism of injury usually axial loading. Classically see overhanging lateral masses of C1. Frequently accompanied by other C/S injuries. Tear-Drop Fracture Two mechanisms: Extension: A stable injury The result of an avulsion of anterior body by ALL. Flexion: A highly unstable injury The result of compressive forces, often with extensive damage to the posterior elements. Normal Pediatric C/S What s Wrong Here? Vertebral bodies are oddly shaped. Disc heights and joint spaces appear larger. Endplates appear to be separated. Right Sided Aortic Arch This is an uncommon congenital anomaly. (0.1% of the population) May be associated with other more serious congenital heart diseases. Thoracic Spine Imaging Standard radiographic series AP Lateral Of course, it s possible that the technician simply placed the marker on the wrong side 5

6 Standard Thoracic Spine Series AP Lateral Thoracic Spine Imaging Accessory radiographic views PA Chest Accessory Thoracic Spine Views PA Chest Thoracic Spine Imaging Common pathology seen on X-rays Osteoarthritis Degenerative disc disease Facet arthrosis Costotransverse arthrosis Scoliosis Compression fractures Rib fractures Thoracic Spine Imaging Common pathology not seen on X-rays Early Infection Early osteoporosis Asthma Ununited TP Of T1 T1 Smooth/round borders Upper thoracic spine is a very common location. This is a very uncommon location for fractures. DDx: TP fracture Rib fracture HADD of the scalenes 6

7 20 yof with c/s and t/s pain Hair Artifacts What happened here? Multiple metallic curvilinear densities. Seen outside the chest. Here s another patient with the same mystery Acupuncture needles!! What went wrong? This is an unaltered (not cropped) image taken at a chiropractic office. Intended to be a lateral thoracic spine view. What went wrong? Cassette not pushed in all the way. Even digital machines use cassettes (CR) QUIZ Lumbar Spine Imaging 1) Which of the following levels o6en gives the false appearance of facet fusion? 2) Which of the following is considered a sign of pathology? Standard radiographic series AP (or PA) Lateral a) C1/2 b) C2/3 c) C3/4 d) C5/6 a) Nuchal bones b) Intercalary bones c) Mach bands d) Ununited growth centers 7

8 Standard Lumbar Spine Series AP Lateral Lumbar Spine Imaging Accessory radiographic views AP (or PA) L5/S1 spot Lateral L5/S1 spot Obliques Flexion/Extension Accessory Lumbar Spine Views Anterior or Posterior Obliques Accessory Lumbar Spine Views Flexion Extension R Accessory Lumbar Spine Views Lateral L5/S1 Spot AP L5/S1 Spot Lumbar Spine Imaging Common pathology seen on X-rays Osteoarthritis Degenerative disc disease Facet arthrosis Ankylosing Spondylitis Compression fractures DISH Atherosclerosis of the Abdominal Aorta Congenital anomalies 8

9 Lumbar Spine Imaging 16yoF with lbp Common pathology not seen on X-rays Disc herniations Sciatica Piriformis Syndrome 16yoF with lbp Normal Transverse Processes 50yoF with lbp Metastatic Breast Cancer (Blastic) Ivory Vertebra DDx: Blastic Metastasis Lymphoma Pagets Disease Notice the osseous destruction of the TP. 9

10 56yom with lbp 48yom with lbp Limbus Bones 38yof with lbp Very common in the lumbar spine. Represent intravertebral disc herniations. Typically asymptomatic (especially if anterior). R Gall Stones 39yom with lbp following MVA Located in the right upper quadrant. Tend to be more dense around the periphery. Common in females over 40. May or may not be symptomatic. 10

11 Hydroxyapatite deposition disease Aka: Calcific tendinitis Cloud-like calcification Most common locations: Shoulder Hip Wrist Transitional Segment Commonly seen at the lumbosacral junction. 7 Subtypes: 35yom with lbp following MVA Swallowed Piercing Patient reported swallowing a piercing during car accident Doctor did not specify what kind of piercing. 29yom with lbp Ankylosing Spondylitis Common in young males. May just present with low back stiffness. Vertebral body squaring and erosions. SI joint fusion occurs in at least 50% of patients. Bilateral symmetry is classic. 11

12 Extremity Imaging Upper extremity Hector RiveraMelo, DC, DACBR Common indications for extremity imaging Unresponsive to care after 4 weeks Significant activity restriction >4 weeks Non-mechanical pain Osteoarthritis unrelieved by conservative care Suspected/known inflammatory arthritis Significant trauma Suspected physical abuse in children Extremity Imaging Red flag indicators Signs/symptoms or history of cancer Red skin, fever, immunosuppressed History of non-investigated trauma Unexplained significant sensory/motor deficit Shoulder Imaging Standard radiographic series AP internal rotation AP external rotation Baby arm Standard Shoulder Series AP Internal Rotation AP External Rotation Standard Shoulder Series Baby Arm 12

13 Shoulder Imaging Accessory Shoulder Views Axial Accessory radiographic views Axial Trans-scapular Y Accessory Shoulder Views Trans-scapular Y Shoulder Imaging Common pathology seen on X-rays Hydroxyapatite Deposition Disease (HADD) AC injuries (grades II-III) Glenohumeral dislocations Osteoarthritis (especially AC) Clavicular fractures Shoulder Imaging 44 Year-old M Common pathology not seen on X-rays Rotator cuff injury Adhesive capsulitis Impingement syndrome Labral injury AC injury (grade I) 13

14 44 Year-old M 44 Year-old M Absent 4 th Rib on the left 79yoM: Acute shoulder pain Examine the whole film: Don t forget the ribs on shoulder views. Potential causes include: Post-surgical Aggressive tumor Clavicle fx with multiple rib fxs Ribs 2 and 3 involved No pneumothorax Significant Osteoporosis 1) Which of the following is a common pathology seen on lumbar spine x- rays? QUIZ 2) Which of the following is a standard view of the thoracic spine? a) Disc hernialons b) Atherosclerosis c) SciaLca d) Piriformis Syndrome a) AP thoracic b) PA thoracic c) AP chest d) PA chest 14

15 Wrist Imaging Standard Wrist Series PA Lateral Standard radiographic series PA Lateral Medial oblique PA ulnar deviation Standard Wrist Series Medial Oblique PA Ulnar Deviation Wrist Imaging Accessory radiographic views Carpal Tunnel Angulated Scaphoid Accessory Wrist Views Carpal Tunnel Angulated Scaphoid Wrist Imaging Common pathology seen on X-rays Osteoarthritis (especially 1 st CMC joint) Scaphoid fractures Distal radial fractures Instability Lunate dislocations Inflammatory arthritis Avascular necrosis 15

16 Wrist Imaging Common pathology not seen on X-rays Nerve entrapment syndromes Ganglion cysts Sprain/Strain Hand Imaging Standard radiographic series PA Lateral Medial oblique Standard Hand Series PA Lateral Medial Oblique Hand Imaging Common pathology seen on X-rays Osteoarthritis (especially DIPs) Metacarpal fractures (especially 4 th & 5 th ) Interphalangeal fractures/dislocations Avulsion injuries Inflammatory arthritis (especially MCPs) Benign Enchondromas Penetrating injuries Hand Imaging 38yof w/ trauma and thumb pain Common pathology not seen on X-rays Nerve entrapment syndromes 16

17 Enchondroma with path fracture Benign cartilagenous lesion with very low rate of malignant degeneration. Represents the most common benign tumor of the hand. Lower extremity Typically asymptomatic until fracture occurs. Occasionally found incidentally. Hector RiveraMelo DC, DACBR Hip Imaging Standard Hip Series AP Pelvis Standard radiographic series AP Pelvis AP Spot Frog Leg Standard Hip Series AP Spot Frog Leg Hip Imaging Accessory radiographic views Judet Long bone study of the femur 17

18 Accessory Hip Views Judet Long bone study Hip Imaging Common pathology seen on X-rays Osteoarthritis Avascular necrosis Hydroxyapatite Deposition Disease (HADD) Developmental dysplasia of the hip Femoral-acetabular impingement syndrome Femoral neck fractures Inflammatory arthritis Hip Imaging 65 yom 1 year post-surgery follow up Common pathology not seen on X-rays Sciatic or other nerve impingement syndromes (piriformis syndrome) Labral injuries Bursiits Muscle tears 65 yom 1 year post-surgery follow up Pre-Op Seen commonly in long bones. Nutrient Canal From the knee we flee! To the elbow we go! Typically will not see medullary involvement Smooth with no cortical offset. Post-Op 18

19 20of w/ hip pain Simple Bone Cyst AKA: Unicameral Bone Cyst Benign cystic lesion with no malignant degeneration. Common in long bones (humerus=mc location) Typically asymptomatic until fracture occurs. Occasionally found incidentally. QUIZ Knee Imaging 1) Which is the most common benign tumor of the hand? a) Osteoid Osteoma b) Osteochondroma c) Enchondroma d) Metastasis 2) Which of the following is a standard view of the hip? a) Frog- leg b) Lateral pelvis c) Lateral spot hip d) Judet Standard radiographic series AP Lateral Standard Knee Series AP Lateral Knee Imaging Accessory radiographic views Oblique Tangential (Sunrise) Intercondylar (Tunnel) Long bone studies 19

20 Knee Accessory Views Intercondylar (Tunnel) Knee Accessory Views Medial Oblique Long bone study Tangential (Sunrise) Knee Imaging: Ottawa Knee Rules Catch high percentage of fractures of the knee Order x-rays of the knee if there is trauma to the knee and any of the following: Age 55 Isolated tenderness at: Head of the fibula Patella Inability to flex knee >90 Inability to walk 4 weightbearing steps at presentation or at presentation Knee Imaging Common pathology seen on X-rays Osteoarthritis Osteochondral defects (femur) Calcium pyrophosphate deposition disease (CPPD) Proximal fibular/tibial fractures Aggressive and benign 1 bone tumors Knee Imaging 59 yof with bilateral knee pain Common pathology not seen on X-rays Patellar tendinitis (Jumpers knee) Meniscal injury ACL, PCL, MCL, LCL injury Sprain/Strain Chondromalacia Patella Osgood-Schlatter disease* 20

21 49 yof with bilateral knee pain Osteoarthritis of the knees Age range is typically <45 Typically asymmetric involvement. Prominent osteophytes Medial joint compartment typically affected 1st. 31 yom with right knee pain Fabella A sesamoid bone. Located within the tendon of the lateral head of the gastrocnemious muscle. A very common normal variant. 41 yof with right knee pain Cyamella A sesamoid bone, similar to the fabella. Located within the tendon of the popliteus muscle. A normal variant 21

22 Meniscal Ossicle An accessory ossicle. Located within the meniscus. Typically seen posteriorly and medially May be triangular. An uncommon normal variant. 66 yom with left knee pain Popliteal Artery Atherosclerosis This is a common location for atherosclerosis. The popliteal artery is the most common location for peripheral aneurysms. Will often see accompanying atherosclerosis of other large arteries. 44 yom with bilateral knee pain 44 yom with bilateral knee pain 22

23 Synovial Osteochondromatosis 35 yom with right knee pain AKA: Synovial Chondrometaplasia, Synovial Chondromatosis Caused by flaking off of synovial lining. The knee is the most commonly affected joint May be 1 or 2 to osteoarthritis 2:1 Male:Female ratio Infrapatellar Fat Pad Syndrome 12yom with right leg pain AKA: Hoffa s Disease Rare cause of knee pain Caused by injury (acute or chronic) to the fat pad. May be pinched with full extension Seen in jumping and kneeling athletes. DDx for anterior knee pain: Patellar tendonitis Synovial chondromatosis Ganglion Cysts Chondromalacia Patella 12yom with right leg pain Lymphoma Abnormal periosteal reaction of tibia DDx. Osteosarcoma Ewing s Sarcoma Osteomyelitis Lymphoma Leukemia 23

24 More Acupuncture Needles!! Foot Imaging Standard radiographic series DP Lateral Medial oblique Standard Foot Series DP Medial Oblique Standard Foot Series Lateral Foot Imaging Accessory radiographic views Tangential Calcaneus (Harris-Beath) Accessory Foot Views Tangential Calcaneus (Harris-Beath) 24

25 Foot Imaging Common pathology seen on X-rays Osteoarthritis (especially 1 st MTP) Phalangeal fractures (especially 4 th & 5 th ) Interphalangeal fractures/dislocations Avulsion injuries Inflammatory arthritis (especially MCPs) Foot Imaging Common pathology not typically seen on X-rays Plantar fasciitis Mortons neuroma 38 yom with foot pain Os Peroneum And Os Intermetatarseum Os Peroneum A sesamoid bone within the peroneus longus tendon. Os Intermetatarseum An accessory ossicle which may form a synovial joint with the first or second metatarsal or medial cuneiform. 22 yom with foot pain Os Vesalianum Ossicle, representing an ununited secondary growth center at the styloid of the 5 th metatarsal. 25

26 27 yof with foot pain 5 th Metatarsal Fracture Avulsion fracture of the 5 th metatarsal styloid. Occurs at the insertion of the Peroneus brevis tendon. Relatively common among tennis players Generally respond well to conservative treatment (casting) QUIZ How to have your films read: 1) Which of the following is a pathologic finding in the knee? a) Fabella b) Cyamella c) Meniscal Ossicle d) Atherosclerosis 2) Which of the following is an accessory view of the knee? a) Intercondylar b) AP c) Lateral d) Femoral Head SCU hectormelo@scuhs.edu We re also on facebook! 26