Midterm

Question 1

1. What is the relation between occipitalization and basilar invagination?

Answer 1

Occipitalization is the non-segmentation (or separation) of C1 and the occiput. Fusion would help you differentiate congenital versus acquired. Would appear as no space b/t occiput and C1 on xray (looks like C1 missing).
Occcipitalization may exist in isolation or occur with basilar invagination and usually the encroachment (>8mm) of the odontoid into the foramen magnum (measured by McGregor’s line). Basilar invagination occurs when the top
of the C2 vertebrae migrates upward. It can cause the opening in the skull where the spinal cord passes through to the brain (the foramen magnum) to narrow.

Question 2

2. Where is posterior ponticle?

Answer 2

Common variant on C1 that contains the vertebral artery and the 1st cervical nerve. The condition may compress and traction the vertebral artery during neck manipulation.

Question 3

3. What is the significance of George’s line?

Answer 3

George’s line describes the line drawn along posterior surfaces of the vertebral bodies on lateral views. The line should make a smooth curve form C1 to C7 (also used in thoracic and lumbar). Disruption indicates a segmental
anterolisthesis (L5 common) or retrolisthesis of one segment on another. Other key landmarks to look at are the superior and inferior corners.

Question 4

4. Why is an os odontoideum clinically significant?

Answer 4

The odontoid has broken off the body of C2 and it can be very dangerous to do a cervical adjustment. The joint is unstable (C1 can move independently of C2) and may be held together only by the transverse ligament. Often this
anomaly is due to a childhood injury.

Question 5

5. What are the radiographic differences between an anomalous block vertebra and an acquired fusion of the spine?

Answer 5

A Block vertebra is non segmentation of 2 adjacent segments resulting in decreased AP diameter, rudimentary disk (small disk space), apophyseal joint fusion (posterior arch fusion) and fusion of the SPs. Called a “wasp waisted”
appearance. Problem is that it creates DJD at adjacent joints (i.e if C3-4 are blocked…C2 and C5 have issues). More likely to occur in cervical.

In acquired fusion of the spine (surgical) on the otherhand the disc is removed and the two adjacent vertebra are fused together. On xray no disc is seen since it has been removed. This is more common in the lumbar spine.
Congenital fusion is Klippel – Feil, also having no disks.

Question 6

6. What is the significance of the spinolaminar junction and spina bifida oculta in the lateral view?

Answer 6

•
Spina bifida oculta results in failure of fusion of the two posterior arch ossification centers producing a midline defect.
•
Because the lamina fail to fuse, this generally appears as a cleft SP on AP view.
•
Yet this spinolaminar junction is often not visible on lateral view

Question 7

7. Why is it common to see disc space narrowing adjacent to a limbus vertebra and/or Schmorl’s node?

Answer 7

•
It is due to an intra body herniation of disk material. The nucleus pulposus herniates through the vertebral endplate.
•
It is usually due to trauma, but can also be due to a weak endplate or a pathologic process such as osteoporosis. Pain is usually asymptomatic.
•
On lateral radiograph you see focal indentation into vertebral body with sclerotic margin. (Look like chips of the endplates) The herniation goes through the ring apophysis (the secondary growth center). See Picture on Right
•
Associated disc usually narrowed.

Question 8

8. How can you tell whether a rib at the cervicothoracic junction is a cervical rib or first rib?

Answer 8

•
The orientation of the transverse processes
o
If they point up, thoracic
o
If they point down, cervical
o
Cervical ribs are usually isolated to the C7 segment
o
They are only bilateral 2/3 of the time.
o
They may fuse to the 1st rib.
o
Other symptoms of cervical ribs:
o
Thoracic outlet syndrome, drooping of the shoulders and increased thoracic kyphosis.
o
Cervical ribs are most common at C7, C6, C5.
o
Articulation with TP differentiates from hyperplastic TP

Question 9

1. Name a dysplasia that may present with tall stature and hypermobile joints?

Answer 9

MARFAN’S SYNDROME

This is a disease of the connective tissue with abnormal collagen formation.

Question 10

What complications may be associated with this condition (Marfans)?

Answer 10

• Consists of long, slender tubular bones, ocular abnormalities, and aneurysm of the aorta.
• Underdevelopment and hypotonicity of the muscular system contributes to joint laxity and dislocation
• Hip dislocations, genu recurvatum (knee bends backward), patellar dislocations, and pes planus (flat feet)
• Myopia and pectus excavatum.

Question 11

What neurologic condition may these individuals have that affects the legs (Dwarfism)?

Answer 11

• In the infant, the small foramen magnum and hydrocephalus can lead to cord compression. In the adult, congenital spinal stenosis often leads to paraplegia.

Question 12

1. What are the radiographic findings of new vs. old fractures?

Answer 12

Step defect (rounds over with time), zone of impaction (for a couple months), osteophytes (from increased DJD)

Question 13

2. What are the possible long bone fracture orientations?

Answer 13

Transcervical (across neck), Intertrochanteric (between G and L trochanter), Subcapital (right below head)

Question 14

3. What are the types of incomplete fractures of pediatric long bones and how do they differ?

Answer 14

Torus - buckling of cortex
Greenstick fractures - incomplete fracture - one side of the bone is broken, the other side is bent.
Bowing - bending with no obvious cortical defect
Growth plate fractures - specific locations due to increased growth during childhood.
[Dislocated “slipped” epiphysis of the femoral head (only older children 10-17 years)]

Question 15

4. Which is the most common type of Salter Harris fracture?

Answer 15

The most common type of Salter Harris fracture is a TYPE II fracture, which goes through the growth plate and metaphysis
Type I: through growth plate no bone involvement
Type III: gp + epiphysis
Type IV: metaphysic + gp + epiphysis
Type V: compression of gp (have to compare to non-invovled side to dx)

Question 16

5. What is the difference between a malunion and a nonunion fracture?

Answer 16

Nonunion of a fracture refers to the absence of healing in a fracture. Malunion of a fracture refers to the healing of a fracture with incorrect anatomical alignment (so it does fuse just incorrectly)

Question 17

6. What significant finding is demonstrated in the APOM view with a Jefferson’s fracture?

Answer 17

A Jefferson fracture is a burst fracture of the atlas (he mentioned in class to think of it like a life saver candy… when you try to break it, it usually breaks into many pieces rather than just a chip off the side). To qualify as a
Jefferson fracture there needs to be at least one fracture in the anterior arch and one through the posterior arch as well. The APOM view is the open mouth view. With this view you will look for increased lateral paraodontoid
space bilaterally. There will be lateral masses of C1 that have slid laterally (>3mm). Often times there is swelling present also.
Notice in the picture how there is lateral offset of C1 on C2 bilaterally

Question 18

7. What is traumatic spondylolisthesis and what cervical level does it usually occur at?

Answer 18

Traumatic spondylolisthesis is also called Hangman’s fracture. It usually occurs at C2. It is a bilateral pedicle (pars) fracture, which is often the result of a MVA.
Hangman’s Fx

Question 19

8. What are the key radiographic differences between an un-united secondary ossification center of the spinous process at the cervicothoracic junction and a clay shoveler’s fracture?

Answer 19

A clay shoveler’s fracture (most common at C7, shown in pictures):
Lateral view shows inferiorly displaced SP
AP view shows “double spinous process” sign (looks like 2 SP’s on a single vertebrae)
Un-united secondary ossification center of the SP:
Fracture will be displaced caudally with jagged edges

Question 20

1. What is the most common fracture of the spine and how do you differentiate new from old? (hint: it occurs usually at T12-L2)

Answer 20

Differentiation of old versus recent compression fracture:
Hemorrhage, hematoma, step defect (new compression fracture), and zone of impaction indicate fracture less than 2 months old
Old fractures often show contiguous disc degeneration (DJD)
Bone scans may show “hot spots” for up to 24 months

Question 21

1. List and describe the unstable fractures of the pelvis.

Answer 21

Unstable fracture - one that may move during healing and result in neurologic damage. In the pelvis, a fracture that may cause significant organ or vascular damage. Fx of both ant. and post arches. 33% of pelvic vx. Usu dt 
significant trauma (ie MVA). Malgaigne (MC, 14% of all pelvic fx), and bucket handle fx. 
Stable fracture - one that will not move during healing and poses no threat to the spinal cord/cauda equina. In the pelvis, no threat to organs or vasculature. Fx w/ a single break in ring! Usu dt moderate fall, etc. 66% of pelvic fx.

Question 22

What is the most common type of acetabular fracture?

Answer 22

Central Acetabular Fracture (aka Explosion Fracture)

Question 23

What is the most common hip (proximal femur fracture) and what age do these often happen in?

Answer 23

Subcapital Fracture. Often missed. Most common in the elderly, and women 2x as often as men

Question 24

Name and describe the proximal femur fracture that happens only in adolescents.

Answer 24

Slipped Capital Femoral Epiphysis
* Patient is usually 10-15 yo
* Usually occurs during rapid adolescent growth period, the femoral neck slips up off the femoral head
* Actually a fracture (Salter-Harris Type I, at growth plate only)
* 20-30% occur bilaterally
* Only about 50% have a history of trauma
* More common in males, but bilateral involvement more commonly in females
*
If it is to be bilateral, the second slips within a year
Associated with:
* Renal osteodystrophy, rickets, radiation therapy
* Best view is frog leg view
* Abnormal klein’s line

Question 25

Which direction does the patella usually dislocate?

Answer 25

Usually superolateral dislocation: may also move horizontally or vertically

Question 26

1. What is a Jones’ fracture and what bone does it occur in?

Answer 26

Most common foot injury. Dancer’s fracture. The transverse fracture of the base of the 5th metatarsal. Usually more transverse.

Question 27

Name an associated injury that must be evaluated for when a patient presents with a calcaneal compression fracture.

Answer 27

10% are associated with thoracolumbar spinal fxs- either compression or burst- must rule these out
Calcaneus is the most frequently fx tarsal bone- fx line often cannot be visualize therefore need Boehler’s angle. Less than 28 deg = compression fx

Question 28

What are the different types/grades of acromioclavicular joint sprain?

Answer 28

The three landmarks used:
Acromioclavicular joint space

• Should be bilateral and symmetrical, within 2-3 mm of each other, and averages between 2-4 mm in absolute width
  Acromioclavicular alignment
• Inferior margins of the clavicle and opposing acromion should be smooth and horizontal
  Coracoclavicular distance
• Normally 11-13mm (distance between inferior margin of the clavicle and the closest surface of the coracoid)
• There should be no more than a 5mm difference between right and left
  Classification of AC injuries:
• Type I: Mild Sprain
• Acromioclaviclar ligament is stretched
• Coracoclavicular lig is intact
• Wt bearing doesn’t increase joint space or alter alignment
• Normal radiograph
• Type II: Moderate Sprain
• Acromioclavicular ligament is torn
• Coracoclavicular lig is stretched
• Widened jt space, slight elevation of clavicle possible
• Type III: Severe Sprain
• Acromioclavicular ligament disrupted
• Coracoclvicular ligament disrupted
• Widened joint space
• Elevation of distal clavicle above acromion
• Coracoclavicular space > 5mm than contralateral side
  Type I and II can be managed conservatively, type III requires joint repair and open fixation

Question 29

What are Hill-Sachs/Hatchet and Bankart lesions and what are they associated with?

Answer 29

Hill-Sachs/Hachet defect is an impaction fx of the posterolateral humeral head (Best seen on AP with internal rotation, and even better on MR). Bankart lesions are inferior glenoid fxs seen with anterior glenohumeral joint dislocation. Hill-Sachs/Hachet defect and Bankart lesions are both associated with anterior dislocation of the humerus from the glenohumeral joint and fracture of the inferior glenoid rim from a posterior impaction injury.
A Hill-Sachs lesion, also Hill-Sachs fracture, is a cortical depression in the posterior superior head of the humerus bone. It results from forceful impaction of the humeral head against the anteroinferior glenoid rim when the shoulder is
dislocated anteriorly

Question 30

Which part of the clavicle most commonly fractures?

Answer 30

Middle Clavicle Fx is most common (80%)—medial fragment displaces superiorly due to pull of the SCM, the distal fragment displaces inferiorly due to the weight of the shoulder and upper extremity.

Question 31

What is the significance of the elbow fat pad signs (anterior and posterior)?

Answer 31

The significance of elbow fat pad signs is that they are clinical signs of an intraarticular fx of the elbow with displacement of the anterior and/or posterior fat pads from between the fibrous and synovial layers of the humeral joint capsule.
Not normally visible, the fat pads become visible from the intraarticular effusion and edema. 90% of children’s elbow fxs have visible posterior fat pads (less frequently seen in adults; absence of sign doesn’t preclude fx). A
posterior fat pad is always abnormal.

Question 32

What structures are involved in the most common fractures of the elbow in children and in adults?

Answer 32

Structures most commonly involved with elbow fxs in children is supracondlyar fxs (transverse or oblique fx above condyles) of the distal humerus (60%), and in adults is radial head and neck fxs (50%) (usually viewed as
vertically oriented radiolucent fx lines; “Chisel fx”). Adults second most common elbow fx at olecranon (20%).

Question 33

What are the most common wrist fractures seen in each of the following age groups: children, young adults, elderly?

Answer 33

Most common wrist fx: children(6-10yo)—Distal Radius Torus Fx; usually 2-4cm proximal to distal growth plate; have ductile bones! 
Young adults(15-40yo)—Scaphoid Fx (PA view with ulnar deviation); occult fx, acute fx line may not be visible until 20 days post-injury, 70% at scaphoid waist; 

Elderly—Colles’ Fracture (from fall on outstretched hand); distal radius fxed ~20-35mm proximal to jt surface, distal fragment is angulated posteriorly, and in 60% of cases the ulnar styloid is also fxed, brittle bones!

Question 34

Describe the difference between Colles’ and Smith’s fractures at the wrist.

Answer 34

• Colles’s fx goes posterior “The collie goes in the back door” –FOOSH fx so wrist is exteneded
• Smith’s fx goes anterior “Mr. & Mrs. Smith go in the front door”–fx dt fall with wrist in hyperflexion therefore “Reversed” Colle’s fx

Question 35

Discuss the vascular supply of the scaphoid and its effect in avascular necrosis and healing of this structure after fracture.

Answer 35

The scaphoid has three anatomical areas: proximal pole, waist, and distal pole. There are only two sources of blood supply to the scaphoid, one to the waist and one to the distal pole. The proximal pole does not have its own
bld supply therefore a fx at the proximal pole can lead to AVN (and does ~15% of the time) dt lack of blood supply and subsequent inability to heal. AVN can be dxed via x-ray bc it will show up whiter than the
surrounding bone.

Question 36

What is the most common carpal bone to dislocate and in what direction?

Answer 36

The Lunate is the most frequently dislocated carpal—is dt a Hyperextension injury
The Lunate tilts forward and anteriorly thus isrupting its articulation with the capitate, but maintains close approximation with the anterior rim of the radius
Lateral view displays the anterior tilt
PA view - Lunate looks like a triangle, apex points distally – “pie sign”

Question 37

What are barroom and boxer’s fractures of the hand?

Answer 37

Boxer’s Fracture: Transverse fracture of second or third metacarpal neck
Caused by impact of short, straight jabbing blow
Barroom Fracture: Transverse fracture of fourth or fifth metacarpal neck
Caused by “roundhouse” blow
* Barroom and boxer’s fracture result in anterior angulation of the metacarpal head and shortening and rotation of distal fragment

Question 38

What is gamekeeper’s thumb?

Answer 38

First metacarpophalangeal tear or rupture of the ulnar collateral ligament
Abduction stress view of thumb shows widened ulnar side of MCP joint, indicating instability
May have a chip fracture, with small fragment from ulnar margin of proximal phalanx base
MRI will demonstrate ulnar collateral ligament lesion

Question 39

How can stress fractures be detected on plain x-ray?

Answer 39

Often occult; requires bone scan or delayed plain film images (latent period = 10-21days)
50% of stress fxs never show x-ray findings
(decent description of imaging stress fractures on emedicine http://emedicine.medscape.com/article/397402-imaging )

Question 40

What are the most common types of spondylolisthesis in the lumbar spine?

Answer 40

90% of all spondylolytic spondylolistheses involve the L5 segment.
Most degenerative spondylolistheses occur at L4.

Question 41

Discuss the differences between spondylolytic spondylolisthesis and degenerative spondylolisthesis. Make sure to include the etiology of each and what spinal level are they most common at.

Answer 41

Spondylolytic spondylolisthesis : anterior displacement of a vertebra (pars)

-Etiology:
biomechanical stress –
usually results in pars interarticularis fracture (spondylolysis)
Spondylolysis is the most common cause of spondylolisthesis in pediatric patients
Only 2 – 3% show progressive displacement. If so, they are usually between 5 – 15 and F (2x >M)

-3 Subtypes:

Subtype a: Most common - it is a stress (fatigue) fracture.
Subtype b: Elongation of pars without defect due to repeated stress fracture with healing.
Subtype c: Acute pars fractures but are rare.
-Spinal level-

Usually at L5 in young active individuals (extension activity - wrestlers, gymnasts, high jumpers).

Spondylolysis: a defect in the pars interarticularis of a vertebra
-Etiology:
Repetitive microtrauma

Congenitally slender pars may predispose to stress fracture
Acute fracture -rarely
Not recorded in infants
Stress fracture factors
Fatigue fx caused by mechanical stress at L/S lordosis
Hyperextension loading (carrying heavy backpack)
Onset M/C after 5 yo – probably d/t upright posture and ambulation
Premature walking
Divers, gymnasts, pole-vaulters, weight-lifters
Non-union d/t lack of immobilization

Degenerative spondylolisthesis:

Consists of disc space loss and loss of cartilage in the facet joints which allows the superior vertebra to slip forward.
Not more than 15-25% anterior slip.
Most common at L4, females, and over 40 years of age.
No neural arch defect.

Question 42

What is the Meyerding’s grading system?

Answer 42

Lateral lumbar projection.
The sacral base is divided into 4 equal sections.
Grade 1 The posterior-inferior corner of L5 is aligned with the first division 1 to 25%

Grade 2 “ “ second division 26 to 50%
Grade 3 “ “ third division 51 to 75%
Grade 4 “ “ fourth division 76 to 100%
Grade 5 is spondyloptosis (L5 anterior to S1) >100%

Several methods exist for radiographically characterizing the degree of spondylolisthesis. The most common is the Meyerding classification in which the degree of subluxation is described as the percentage of translation of the upper VB

over the lower one. The categories include Grade I (0-25% subluxation), Grade II (25-50% subluxation), Grade III (50-75% subluxation), and Grade IV (75% subluxation).[16,17] Complete or 100% spondylolisthesis is termed

spondyloptosis (Fig. 3).

Whereas the Meyerding classification only takes into account translational subluxation, other measurements take into account the angular displacement that can occur in spondylolisthesis. The “slip angle” or sagittal rotation measures the
degree of lumbosacral kyphosis. This is calculated by measuring the angle formed by the intersection of two lines: 1) a tangent to a line drawn along the posterior aspect of the sacrum; and 2) a line parallel to the inferior endplate of
L-5. In the normal situation, the angle formed by the intersection of these two lines measures zero. The “tilt” or sacral inclination refers to the vertical position of the sacrum, which is measured by drawing a line perpendicular to the
floor and measuring the angle formed by the intersection of this line with a second one drawn parallel to the posterior aspect of the sacrum. Usually this angle should be greater than 30°; as the sacrum obtains a more vertical

position, this angle becomes progressively smaller.[3,11,16,29]

Question 43

What is an inverted/ reversed Napoleon hat sign?

Answer 43

Inverted Napoleon’s hat sign or bowline of Brailsford seen with significant anterolisthesis.
.
On imaging the body of L5 slides forward enough to give a look of an upside down Napoleon hat. This only occurs if there is significant slippage of anterior portion of L5 off of the sacrum. There is bilateral pars fracture of the
vertebrae that allows this slippage. There isn’t necessarily nerve damage or impingement as the cauda equine will follow normal path.

Question 44

2. What is the most common cause of dwarfism?

Answer 44

Achondroplasia -bone growth disorder responsible for 70% of dwarfism cases

Question 45

3. Fragile osteopenic bones are associated with which dysplasia?

Answer 45

Osteogenesis Imperfecta

Osteoporosis with abnormal fragility of the skeleton, blue sclerae, mb abnormal dentition

Question 46

9. What is a transitional lumbosacral vertebra?

Answer 46

• When you see an undifferentiated L5 or S1 (or partially fused).
• Transverse process is spatulated (>19 mm vertically) unilaterally or bilaterally
• May form accessory joints with sacral alae or be fused to sacrum.
• L/S disc hypoplastic.
• Degeneration often present.
  Dysplasias

Question 47

1. What is the radiographic difference in anterior vs. posterior glenohumeral dislocations? Which is most common?

Answer 47

• ~95% of glenohumeral dislocations are anterior
  Anterior:
  Humeral head may settle in: Radiologic signs:
  subcoracoid (most common) Inferior and medial displacement
  subglenoid Altered humeral head shape
  subclavicular Hill-Sachs defect
  intrathoracic Bankart lesions – inferior glenoid fx

Posterior:

Humeral head looks identical in external and internal rotation, because of fixation in its posteriorly displaced position. Humeral head often stays at same level as glenoid or superior to it.
Caused by epileptic convulsions, electric shocks, and direct trauma (ie huge muscle spasm/force pulls it posteriorly)

Question 48

1. What are the common sites of a stress fracture?

Answer 48

Most common locations: 
Metatarsals – aka “march fracture”, “deutchlanders disease” 
Proximal tibia, 
calcaneus, 
distal fibula, 
hook of the hamate, 
distal one third of the clavicle 
L5 pars interarticularis (most common stress fracture in the spine)

Question 49

What imaging type(s) are most sensitve in detecting stress fractures?

Answer 49

Bone scan is sensitive, not specific
CT may delineate fx but later
MRI will show bone edema and fx line earlier than CT
Sensitive and specific

Periosteal response: local periosteal and endosteal cortical thickening

Spondylolisthesis: slippage of one vertebra on another, often assumed to be an anterior slippage (anteriolisthesis). Also may be posterior (retrolisthesis) or lateral (laterolisthesis).
Spondylolysis: Pars interarticularis defect (with or without slippage aka spondylolisthesis). Pain may be present at onset of lysis.