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  1. Posterior Ponticle
    • ossification of the atlantooccipital ligament
    • -partial or full ossification
    • -can alter traversing vertebral artery
    • probably not clinically significant
  2. Os odontoideum
    • non-union of the dens with the axis body
    • mus assess for intability with flexion/extension views
    • may need neurosurgical consult of neuro signs/symptoms present
  3. ossiculum terminale
    • unfused secondary ossification center of the tip of dens
    • stable
  4. Block Vertebrae (congenital)
    • wasp waist appearance
    • *occipitalization of the atlas is analogous to a block vertebrae
    • *a surgically blocked vertebrae will not have anterior concavity
  5. Hemivertebrae
    • failure of ossification of part of the vertebral body
    • can be lateral, ventral or dorsal
    • may result in scoliosis
  6. Butterfly Vertebra
    just know it
  7. Klippel-Feil Syndrome
    • must have congenital bloack of >1 motion segment (more than two bodies) to be considered klippel-feil
    • clinical triad:
    • 1. short webbed neck 2. low hairline 3. reduced cervical ROM
    • may also have occipitalization of C1 and sprengels deformity
  8. Sprengels deformity
    congenital elevation of the scapula due to failure to descend
  9. Omovertebral bone
    • -often seen with sprengels deformity
    • fibrous, cartilaginous or ossific band from the TP, SP, or lamina of C5 or C6 that extends to the superior angle of the scapula
  10. Cleidocranial Dysostosis
    syndrome comprised of various midline defects such as agenesis or hypoplasia of clavicles, pubic symphysis diastasis, cleft palate, supernumery teeth
  11. Transitional segments
    lumbosacral transitional segements may be a pain generator
  12. Pedicle agensis
    contralateral pedicle is sclerotic, ddx from METS
  13. Cervical ribs
    may be associated with TOS
  14. Spina Bifida Occulta
    • at C1, called spondyloschisis
    • often seen at L5 or C1
  15. Clasp-knife deformity
    -Elongated SP, pain with extension
  16. Developmental dysplasia of the hip
    • ortho test: Ortolani's or Barlow's click test, done on infants
    • treated with harness of casting in infancy
    • classic radiographic findings at 4-6 months of age, Putti's triad: 1. absent or small proximal femoral capital epiphysis 2. lateral displacement of the femur 3. shallow acetabulum-
  17. Tarsal coalition
    the tarsals coalesce....
  18. ulnar variance
    • Positive ulnar variance is associated with ulnar impaction syndrome and damage to the TFCC
    • Negative ulnar variance is associated with Kienbocks (AVN of Lunate)
  19. Supracondylar process
    • points TOWARDS the joint line.... toward medial epicondyle
    • may cause median n. or brachial a. impingement
  20. Neurofibromatosis
    • >6 cafe au lait spots with smooth borders (coast of california)
    • fibroma molluscum: elevated cutaneous nodules
    • -neurofibromas and schwannomas
    • - on x ray may find: enlarged IVFs, Posterior body scalloping due to dural ectasia, acute kyphoscoliosis, soft tissue shadows from cutaneous lesions. may also see focal gigantism of one digit/extremity
  21. Achondroplasia
    • large cranium
    • small foramen magnum (risk of neuro/vascular compromise)
    • bullet shaped vertebrae with posterior scalloping
    • champagne glass pelvis
    • horizontal sacrum
    • trident hands
    • short limbs, relatively normal length of spine
    • cervical manipulation is contraindicated
  22. Degenerative arthritis aka spondylosis aka osteochondrosis
    • common at junctional areas of the spine
    • disc space narrowing
    • subchondral sclerosis
    • spondylophyte/osteophyte formation (more horizontal than syndesmophyte)
    • facet arthrosis
    • vacuum phenomonena
  23. Diffuse Idiopathic Skeletal Hyperostosis
    • aka Forestiers disease
    • calcification and ossification of the ALL
    • must have at lease 4 continuous segments
    • ligamentous calcification at spinal and extraspinal sites
    • associated with diabetes
    • may have difficulty swallowing
  24. synoviochondrometaplasia
    • aka osteochondromatosis
    • may have pain and joint locking
    • synovial metaplasia which may form cartilage which can detach and ossify
    • results in multiple intraarticular loose bodies
  25. Neuropathic Osteoarthropathy
    • aka Charcots joint
    • destruction at joint that occurs secondary to loss or impairment in joint proprioception
    • common causes include: diabetes, alcoholism, MS, syringomyelia, neurosyphillis, congenital indifference to pain
    • 2 types: hypertophic (distended joint, density increase, debris, dislocation, disorganization, destruction) and atrophic (resorbed articular surface, tapered bone ends)
  26. Rheumatoid arthritis
    • inflammatory
    • targets synovial jts
    • bilateral and symmetrical
    • uniform joint space narrowing
    • juxtaarticular osteoporosis
    • marginal erosions (usually PIPs)
    • ulnar deviation
    • must assess cervical stability in all inflammatory arthropathies
    • increased ADI (should be less than 3mm)
    • disruption of transverse ligament
    • morning stiffness, joint pain and swelling, positive RA factor, elevated ESR and CRP
  27. Ankylosing Spondylitis
    • Marie Strumpells
    • seronegative
    • bilateral and symmetrical sacroillitis
    • marginal syndesmophytes
    • trolley track spine
    • bamboo spine
    • enthesopathy
    • ankylosis
    • elevated ESR, HLA B27
    • men 15-35
  28. Enteropathic arthritis
    • looks identical to AS radiographically
    • associated with crohns and ulcerative collitis
    • bilateral sacroillitis and marginal syndesmophytes of the spine
  29. Psoriatic Arthropathy
    • hands, feet SI joints and spine
    • arthropathy typically shows up after skin lesions
    • most common in peripheral joins, especially DIPs
    • sausage digits
    • ray pattern: all joints on one digit involved
    • mouse ears appearance in digits due to erosions and fluffy periostitis
  30. Psoriatic spondyloarthropathy
    • bilateral and asymmetric sacroillitis
    • non-marginal syndesmophytes
    • enthesopathy
    • onset age 20-50 equal male to female
    • skin lesions, nail changes
    • ESR is normal
    • negative RA factor
    • positive HLA B27 in 75%
  31. Reiter's syndrome
    • also called reactive arthritis
    • correlation with recent venereal disease
    • cant see, cant pee, cant dance (conjunctivitis, urethritis, arthritis)
    • most common in young men
    • predilection for lower extremity ->lover's heel
    • -jts of the lower extremity: uniform jt space loss, erosions, periostitis, inflammatory enthesopathy
    • -spine: bilateral asymmetrical or unilateral sacroillitis, non-marginal syndesmophytes (same as psoriatic)
    • positive ESR and CRP
    • positive HLA-B27 in 75%
    • negative RA factor
  32. Osteitis Condensans Ilii
    • aka hyperostosis triangularis, condensans triangularis
    • bilateral and symmetrical
    • usually in multiparous women
    • usually self-limiting
    • bilateral triagle sclerosis by SI joints
  33. SLE
    • systemic lupus erythematosus
    • generalized connective tissue disorder
    • mostly women 20s to 30s
    • most characteristic radiographic finding is reversible deformities of the hands and soft tissue calcifications
    • erosive changes not typical
    • *patients undergoing long term CST treatment are predisposed to AVN
    • malar facial rash
    • elevated ESR and TNF
  34. Gouty Arthritis
    • metabolic
    • dense soft tissue tophi
    • preservation of jt space until late
    • erosions (periarticular, intraosseous, and marginal types)
    •  normal bone density
    • males 20X more prominent than females
    • middle aged 
    • elevated ESR, leukocytosis, hyperuricemia
  35. Calcium Pyrophosphate Deposition Disease (CPPD)
    • CPPD crystals are deposited in cartilage (fibrous or hyaline)
    • may cause secondary DJD
    • often at knee and wrist
  36. Hydroxyapatite Deposition Disease
    • 40-70 years old
    • single joint is typical
    • M/C is shoulder
    • calcific tendonitis or bursitis
    • no lab findings
    • self-limiting
  37. If you see a lytic, aggressive lesion in an adult:
    think  mets, myeloma or lymphoma
  38. if you have an epiphyseal/apophyseal lesion, think:
    chondroma, GCT, EG, or infection
  39. Osteoblastic mets most commonly come from:
    • "5 bees lick pollen"
    • brain, bronchus breast bowel, bladder, lymphoma and prostate
  40. Bone-forming tumors:
    • osteosarcoma (10-25 yo)
    • Osteoid osteoma (10-25 yo)
  41. Cartilage-forming tumors
    • osteochondroma
    • enchondroma
    • chondroblastoma (10-25yo)
    • chondrosarcoma (40-60 yo)
  42. Osteosarcoma
    • 10-25 yo
    • usually blastic, but can be lytic or mixed too
    • aggressive periosteal reaction
    • usually in metaphysis of long bone, esp knee
    •  very aggressive ->amputation, chemo, radiation
    • cummulus cloud appearance
    • *parosteal osteosarcoma has a cleavage plane
  43. Osteoid osteoma
    • 10-25 yo
    • cortically located
    • nidus <1cm with a thick rim of sclerosis
    • solid pareosteal reaction
    •  ddx: brodies abcess (subacute osteomyletis
    • pain worse at night, relieved by aspirin
  44. Chondrosarcoma
    • 40-60 yo
    • most common in pelvis and proximal femur
    • arc and ring calcifications, popcorn calcifications
    • tx: surgical excision or amputation
  45. Osteochondroma
    • 75% occur before age 20
    • cortex and trabeculae bend perfectly with parent bone
    • exostosis that points away from the joint line
    • rare malignant degeneration
    • pedunculated or sessile
  46. Enchondroma
    • ages 10-30
    • most common benign bone tumor of the hand
    • geographic, expansile, lytic lesion usually in the smaller tubular bones
    • punctate/stippled calcifications in cartilage matrix
    • centrally placed in the metaphysis
    • may present with fracture
    • rare malignant transformation to chondrosarcoma, odds increase if closer to axial skeleton, 
    • multiple lesions -> multiple enchondromatosis, aka Olliers disease
  47. Chondroblastoma
    aka Codman's tumor
    • 10-25 yo
    • located in epiphysis or apophysis
    • geographic lesion that may have stippled calcification, marginal sclerotic rim, short zone of transition
    • tx: curettage with packing of bone chips
  48. Non-ossifying fibroma
    • 8-20 yo
    • asymptomatic
    •  most common in distal tibia
    • lytic, eccentric, ovoid, thins and expands the cortex
    • multilocular appearance
    • 2-7 cm in length
    • thick sclerotic border along medullary side and central lucency, perhaps with some lobulated insides
    • pareosteal reaction -> scalloping
  49. Fibrous cortical defect
    • 4-8 yo
    • asymptomatic
    • eccentric, lytic, sclerotic rim, may be multiple
  50. Simple bone cyst
    • aka unicameral bone cyst
    • 3-14 yo
    • originates in metaphysis (active), latent in diaphysis
    • proximal humerus, proximal femur
    • cystic radiolucency that is broad at metaphyseal end and narrower at diaphyseal end
    • truncated appearance
    • endosteal scalloping
    • no matrix calcification
    • may have fallen fragment sign or hinged fragment sign
    • Tx: surgical curettage with bone chips
  51. Aneurysmal bone cyst
    • 5-20 yo
    • hx of trauma
    • not a true aneurysm or cyst
    • acute pain with rapidly increasing severity
    • can cross disc
    • likes the posterior neural arch of the spine, long tubular bones
    • metaphysis and eccentric in long bones
    • m/c benign tumor in clavicle
    • 8-10 cm, fast growing, eggshell thin cortex, soap bubbly
    • ddx with osteoblastoma
  52. Giant cell tumor
    • 20-40 yo
    • begins in metaphysics and extends to end of long bone to subarticular region
    • distal femur, proximal tibia, *distal radius (most malignant), proximal humerus, sacrum
    • eccentric, metaphysial in origin, purely lytic, thinned and expanded cortex, soap bubble 
    • tx with curettage and bone chips
  53. Ewings sarcoma
    • 10-25 yo
    • diaphysis of long bones
    • permeative bone destruction with aggressive pereosteal reaction (lamellated/onion skin, condman's triangle), cortical saucerization
    • *only primary bone tumor that simulates an infection (fever, anemia, inc. WBCs, elevated ESR)
  54. Multiple Myeloma
    • average age of 60
    • most common primary bone tumor
    • generalized osteoporosis
    • punched out or moth-eaten lytic osseus lesions
    • elevated serum Ig G (M-spike)
    • Reversal of A/G ratio
    • Bence-Jones proteinuria
    • will not show up on bone scan
    • raindrop skull, pathological compression fractures involving the posterior third of the body
  55. Metatstatic disease
    • can be lytic (M/C), blastic or mixed
    • look for missing pedicle sign 
    • increased acid phosphatase and increased alk phosphatase (if blastic)
    • more common in older adults, hx of cancer
    • lytic mets: permeative bone destruction, no periosteal reaction, no osseous expansion, no disc involvment
    • blastic mets: ivory vertebra
  56. Paget's disease
    • >40 yo
    • oseoclastic resorbtion of bone followed by extensive attempts at repair
    • 4 stages: 1. osteolytic, 2. mixed, 3. osteoblastic, 4. malignant degeneration
    • increased alkaline phosphatase and hypercalcemia
    • can lead to deformity, basilar invagination, pathologic fx, spinal stenosis, high cardiac output failure, malignant degeneration
    • -"blade of grass appearance" in long bones, ivory vertebrae (enlargement of body), picture frame vertebrae, shepherds crook varus deformity of femur, saber shin anterior bowing of tibia, osteoporosis circumscripta in stage one in skull, cotton wool appearance stage 2 in skull, rim or brim sign, pseudofractures/banana fractures, leontiasis ossea, protrusio acetabuli, obliteration of kohler's teardrop
  57. Fibrous dysplasia
    • 8-14 yo
    • imitator of bone disease
    • expansile with cortical thinning
    • look for surrounding rim of sclerosis "rind sign"
    • ground glass appearance
    • typically spares the epiphysis
    • bowing deformities (shepherds crook deformity)
    • cafe au lait spots- coast of maine
  58. Osteoma
    • only in skull
    • usually asymptomatic
    • round, oval, well-circumscribed, uniformly opaque
    • may be associated with Gardner's syndrome
    • <2 cm in size
    • benign
  59. Enostoma/Bone Island
    • M/C age is 40
    • looks like an osteoma but it can be located anywhere except the skull
    • asymptomatic
    • brush border, epiphysis and metaphysis, pelvis
    • round to ovoid sclerotic intramedullary foci
    • not hot on bone scans
  60. Osteoblastoma
    • 10-20 yo
    • located in posterior nuchal arch of spine
    • pain, NOT at night and NOT relieved by aspirin
    • expansile, egg shell thin cortex
    • 2-10cm in size
    • benign, 1% becomes malignant
  61. Hemangioma
    • >40
    • M/C benign bone tumor of the spine
    • easier to see on MRI than plain film
    • if in the spine, leave it alone. if in the skull (except mandible/maxilla), remove
    • high signal on T1 and T2
    • corduroy cloth appearance
    • hemangioma of skull: in frontal bone, 1-7cm, round or oval, sunburst or spoke wheel appearance
  62. Non-hodgkins lymphoma
    • 20-40 yo
    • knee, femur, tibia, humerus
    • metaphyseal and diametaphyseal
    • laminated pareosteal reaction
    • soft tissue mass later
    • lymphadenopathy causes mediastinal widening later
  63. Hodgkin's lymphoma
    • lytic lesions more symptomatic than blastic
    • vertebral body is m/c site
    • lower thoracic and upper lumbar spine, mostly osteolytic
    • ivory vertebrae
  64. Sickle cell anemia
    • xray changes due to marrow hyperplasia and avn
    • bilateral and symmetrical osteomyelitis is common
    • H-shaped vertebra, fish vertebra, splenomegaly, marrow hypertrophy (mild hair on end appearance)
  65. Thalassemia
    • honeycombing of tabeculae
    • rodent face
    • erlenmeyer flask (widening of bones), widening of small tubuluar bones, hair on end appearance in skull
  66. Hemophilia
    • males only
    • multiple episodes of bleeding into joints, ballooning of the epiphysis, osteoporosis, widening of the intercondylar notch, flattening of the tibial spines
  67. AVN
    • lunate- Keinbocks; associated with neg ulnar variance
    • femoral head in kids- legg calve perthe
    • MT head- freibergs

    consult with ortho surgeon, core decompression if found early enough
  68. Medullary infarct
    • sclerotic lesion with stippled calcifications seen on plain film
    • MRI T1 findings: loss of marrow high signal intensity in the necrotic bone. The dark signal surrounding the lesion is the inflammatory fluid -> double line sign
  69. Osgood-Schlater's disease
    • apophysitis of the tibial tuberosity 
    • irregular, isolated ossicles anterior to the tibial tuberositiy
    • must have pain and swelling to be diagnosed
  70. Infective spondylitis/discitis
    • loss of disc space
    • ireegular destruction of the adjacent vertebral endplates
    • infection starts in the vertebral body and quickly involves the disc
  71. Osteomyelitis
    • permeative pattern of lytic bone destruction
    • solid pareosteal reaction
    • *may resemble mets, but mets will not have a periosteal reaction
  72. Brodie's abcess
    • represents a subacute osteomyelitis
    • round osteolytic area surrounded by sclerosis
    • solid pareosteal reaction
    • similar to osteoid osteoma
    • can be >1cm
  73. Septic arthritis
    • monoarticular
    • joint space narrowing
    • juxtaarticular osteopenia (due to hyperemia)
    • loss of the subchondral bone plate
    • Waldenstrom's sign- >2mm difference of the medial joint space of the hip; indicates hip effusion, which may indicate septic arthritis or legg calve perthe
  74. Open fracture
    penetrates the skin
  75. Comminuted fracture
    2 or more bony fragments
  76. non-comminuted fracture
    bone separated into 2 fragments
  77. avulsion fracture
    tearing away a portion of the bone from a forceful muscular or ligamentous pull
  78. Impaction fracure
    common example is a compression fracture of the vertebral body
  79. Chip fracture
    type of avulsion fracture from the corner of a phalanx or other short or long bone
  80. Perched facets
    • facet dislocation
    • increased retrolaryngeal soft tissue space
  81. slipped femoral capital epiphysis
    • adolescents commonly
    • overweight children
    • knee pain and a limp
    • abnormal kleins line
    • salter harris type 1
  82. Colle's fracture
    • due to FOOSH injury
    • dorsal angulation of the distal radial fragment
    • comminuted fx
    • may need casting for internal fixation
    • distal radius fx
  83. Transverse process fracture
    • must assess for injury to kidney/ureter! (intravenous pyelogram)
    • otherwise a stable fracture that does not require surgery
  84. Teardrop fracture
    • fracture of anteroinferior portion of vertebral body
    • due to major trauma
    • highly unstable, refer to neurosurgeon
    • does not occur in L/S
  85. Hangman's fracture
    • bilateral disruption through the pedicles of the axis
    • highly unstable
  86. Jefferson Fracture
    • burset fracture of the atlas
    • fractures through both the anterior and posterior arches
    • produces lateral offset of the lateral masses
  87. Spondlolytic Spondylolisthesis
    • anterior slip of vertebra due to pars defect
    • MR or SPECT scan can help determine if pars fracture is active
  88. Clavicle fracture
    figure 8 brace may help
  89. Chisel fracture
    • radial head fx
    • subtle, intraarticular radial head fracture
    • anterior and posterior fat pad sign
  90. Monteggia fracture
    • FOOSH injury
    • fracture of proximal ulna with displaced radial head
  91. Galeazzi fracture
    • radial fracture
    • ulnar dislocation
  92. Incomplete fractures
    • only in kids
    • greenstick and torus
  93. Torus fracture
    • cortex buckles outward
    • incomplete fracture
  94. Greenstick/Hickory stick fracture
    • bone bends producing a transverse fracture on the convex side while the concave side remains intact
    • heal without complications
    • incomplete fracture
  95. Hyperparathyroidism
    • rugger jersey spine
    • vascular calcification
    • subperiosteal resorbtion
    • acro-osteolysis
    • lace-like accentuation of trabeculae
    • primary- parathyroid
    • secondary-kidney
    • tertiary- pituitary
    • brown tumors
    • salt and pepper skull
  96. Osteopetrosis
    • Anemia b/c medullary cavity cannot form properly 
    • predisposed to fx (HVLA may be contraindicated)
    • bone within a bone appearance
    • sandwich vertebrae
  97. Rickets
    • kids
    • vitamin D or calcium deficiency
    • bowing deformities
    • physeal widening
    • paint brush metaphysis
    • lack of zone of provisional calcification
    • Rachitic rosary
  98. Scurvy
    • Vit C deficiency
    • Dense zone of provisional calcification (white line of Frankel)
    • Wimberger's ring (dense peripheral ring epiphysis)
    • Corner sign
    • Pelken's spurs
  99. Abdomen: most common things seen
    • hepatomegaly
    • pancreatic calcification
    • AAA
    • atherosclerosis
    • gallstones
    • uterine fibroids
    • renalithiasis
  100. Porcelain gallbladder
    • due to chronic cholecystitis
    • may be pre-malignant
  101. Chest: most common things seen
    • pneumothorax
    • atelectasis
    • bronchogenic carcinoma
    • pleural effusion
    • pancoast tumor
    • pnemonia
    • sarcoidosis
  102. Bronchogenic carcinoma
    • look for Hadley's golden S curve (right side only)
    • visible mass, non-calcified, usually larger than 3cm
  103. Pleural effusion
    meniscus sign (blunting of costophrenic angles)
  104. Pancoast tumor
    • aka superior sulcus tumor
    • tumor in the apex of the lung
    • may have Horner's syndrome (ptosis, anhydrous and myosis)
    • 1st rib destruction
    • can invade brachial plexus
  105. Pneumonia
    • air space disease
    • cloudy appearance
    • silhouette sign
  106. Sarcoidosis
    enlarged hilar lymph nodes (potato nodes)
  107. CT is best for...
    chest, abdomen, acute head trauma, subtle fractures in complex anatomy areas
  108. MRI is best for...
    • everything else!
    • soft tissues, neurologic tissue, bone marrow changes, internal derangement of joints
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