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Hector RiveraMelo DC, DACBR hectormelo@scuhs.edu

Radiographic Imaging

� 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 radiographic series �  AP lower cervical �  AP open mouth �  Lateral

Standard Cervical Spine Series AP Lower Cervical Lateral

Standard Cervical Spine Series AP Open Mouth

Cervical Spine Imaging

� Accessory radiographic views � Obliques �  Flexion/Extension

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Accessory Cervical Spine Views Anterior Obliques

Accessory Cervical Spine Views

Flexion

Extension

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.

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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

Facet Arthrosis

•  Radiographic Features:

•  Hypertrophy (enlargement) of the articular processes

•  Sclerosis •  Anterior or posterior

translations (advanced)

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

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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

•  AKA: Clay-shoveler’s fracture

•  Inferior displacement of fragment

•  Parent/Donor site

•  A stable injury •  DDx:

•  Ununited growth center.

66 yoM with C/S pain

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

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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

•  Vertebral bodies are oddly shaped.

•  Disc heights and joint spaces appear larger.

•  Endplates appear to be separated.

What’s Wrong Here?

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.

•  Of course, it’s possible that the technician simply placed the marker on the wrong side…

Thoracic Spine Imaging

� Standard radiographic series �  AP �  Lateral

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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

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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    

1)  Which  of  the  following  levels  o6en  gives  the  false  appearance  of  facet  fusion?    a)  C1/2  b)  C2/3  c)  C3/4  d)  C5/6  

2)  Which  of  the  following  is  considered  a  sign  of  pathology?  

a)  Nuchal  bones  b)  Intercalary  bones  c)  Mach  bands  d)  Ununited  growth  

centers  

Lumbar Spine Imaging

� Standard radiographic series �  AP (or PA) �  Lateral

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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

R

Accessory Lumbar Spine Views Flexion Extension

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

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Lumbar Spine Imaging

� Common pathology not seen on X-rays � Disc herniations �  Sciatica �  Piriformis Syndrome

16yoF with lbp

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.

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56yom with lbp 48yom with lbp

Limbus Bones

•  Very common in the lumbar spine.

•  Represent intravertebral disc herniations.

•  Typically asymptomatic (especially if anterior).

38yof with lbp

R

Gall Stones

•  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.

39yom with lbp following MVA

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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.

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Upper extremity

Hector RiveraMelo, DC, DACBR hectormelo@scuhs.edu

Extremity Imaging

� 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

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Shoulder Imaging

� Accessory radiographic views �  Axial �  Trans-scapular ‘Y’

Accessory Shoulder Views Axial

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

� Common pathology not seen on X-rays � Rotator cuff injury �  Adhesive capsulitis �  Impingement syndrome �  Labral injury �  AC injury (grade I)

44 Year-old M

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44 Year-old M 44 Year-old M

Absent 4th Rib on the left

•  Examine the whole film:

•  Don’t forget the ribs on shoulder views.

•  Potential causes include:

•  Post-surgical •  Aggressive tumor

79yoM: Acute shoulder pain

Clavicle fx with multiple rib fxs •  Ribs 2 and 3 involved

•  No pneumothorax •  Significant Osteoporosis

QUIZ  

1)  Which  of  the  following  is  a  common  pathology  seen  on  lumbar  spine  x-­‐rays?    a)  Disc  herniaLons  b)  Atherosclerosis  c)  SciaLca    d)  Piriformis  Syndrome  

2)  Which  of  the  following  is  a  standard  view  of  the  thoracic  spine?  

a)  AP  thoracic  b)  PA  thoracic  c)  AP  chest  d)  PA  chest  

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Wrist Imaging

� Standard radiographic series �  PA �  Lateral � Medial oblique �  PA ulnar deviation

Standard Wrist Series PA Lateral

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 1st CMC joint) �  Scaphoid fractures � Distal radial fractures �  Instability �  Lunate dislocations �  Inflammatory arthritis �  Avascular necrosis

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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 4th & 5th) �  Interphalangeal fractures/dislocations �  Avulsion injuries �  Inflammatory arthritis (especially MCPs) �  Benign Enchondromas �  Penetrating injuries

Hand Imaging

� Common pathology not seen on X-rays � Nerve entrapment syndromes

38yof w/ trauma and thumb pain

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Enchondroma with path fracture

•  Benign cartilagenous lesion with very low rate of malignant degeneration.

•  Represents the most common benign tumor of the hand.

•  Typically asymptomatic until fracture occurs.

•  Occasionally found incidentally.

Lower extremity

Hector RiveraMelo DC, DACBR hector.dacbr@gmail.com

Hip Imaging

� Standard radiographic series �  AP Pelvis �  AP Spot �  Frog Leg

Standard Hip Series AP Pelvis

Standard Hip Series AP Spot Frog Leg Hip Imaging

� Accessory radiographic views �  Judet �  Long bone study of the femur

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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

� 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

65 yom 1 year post-surgery follow up Pre-Op

Post-Op

Nutrient Canal

•  Seen commonly in long bones.

•  From the knee we flee! •  To the elbow we go!

•  Typically will not see medullary involvement

•  Smooth with no cortical offset.

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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    

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  

Knee Imaging

� Standard radiographic series �  AP �  Lateral

Standard Knee Series AP Lateral

Knee Imaging

� Accessory radiographic views � Oblique �  Tangential (Sunrise) �  Intercondylar (Tunnel) �  Long bone studies

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Knee Accessory Views

Tangential (Sunrise)

Intercondylar (Tunnel)

Knee Accessory Views Medial Oblique Long bone study

�  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 weight-

bearing steps at presentation or at presentation

Knee Imaging: Ottawa Knee Rules 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

� 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*

59 yof with bilateral knee pain

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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

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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

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Synovial Osteochondromatosis •  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

35 yom with right knee pain

Infrapatellar Fat Pad Syndrome •  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

12yom with right leg pain Lymphoma

•  Abnormal periosteal reaction of tibia

•  DDx. •  Osteosarcoma •  Ewing’s Sarcoma

•  Osteomyelitis •  Lymphoma •  Leukemia

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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)

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Foot Imaging

� Common pathology seen on X-rays � Osteoarthritis (especially 1st MTP) �  Phalangeal fractures (especially 4th & 5th) �  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 5th metatarsal.

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27 yof with foot pain 5th Metatarsal Fracture

•  Avulsion fracture of the 5th metatarsal styloid.

•  Occurs at the insertion of the Peroneus brevis tendon.

•  Relatively common among tennis players

•  Generally respond well to conservative treatment (casting)

QUIZ    

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  

How to have your films read:

� SCU �  http://www.scuhealth.org/DI �  hectormelo@scuhs.edu

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