Exam 1 (X-Ray Images A) Flashcards
(116 cards)
1
Q
What do you do when someone comes in with a skull trauma?
A
REFER out IMMEDIATELY They need a CT
2
Q
Skull Fractures
A
Skull is anatomically complex interpretation is very different less than 10% of skull fracture detected on X-rays
3
Q
Types of Skull Fractures
A
Depression fractures compound fractures Hairline fractures Subdural hematoma
4
Q
What’s the diagnosis?
A
Linear skull fractures are the most commin skull fractures
5
Q
Pathology
A
Linear Skull Fracture
-Most common skull fracture
6
Q
Pathology
-What advanced imaging would help confirm out findings?
A
Linear skull fracture
-CT is the best imaging utilized for skull fractures
7
Q
Pathology
A
Depression Skull Fracture
8
Q
Pathology
-What name is given to this fractured portion of the face?
A
Zygomaticomaxillary Complex Fracture (a.k.a. Tripod Fracture)
-Called an “Elephant’s Head” where the ear is the lateral margin of the orbit, the trunk the temporal process of the zygomatic bone and the eye is the infraorbital foramen
9
Q
Pathology
-What findings help support our Dx?
A
Blowout Fracture
- Fracture of the floor of the orbit
- Fluid inside the right maxillary sinus (should normally be black from air)
-
10
Q
What type of classification of facial trauma are these known as?
A
Le Fort Fractures
11
Q
What type of Le Fort fracture is this?
A
Type I
-Maxilla is separate from the face
12
Q
Pathology
A
Subdural hematoma
-***Convex shaped***
13
Q
Pathology
A
Epidural Hematoma
-***Concave***
14
Q
What are all the mechanisms of trauma that can cause Spinal trauma?
A
- Hyperflexion
- Hyperflexion and rotation
- Hyperextension
- Hyperextension with rotation
- Vertical compression
- Lateral flexion
- Other
15
Q
Trauma associated with hyperflexion injuries
-Which types of trauma are most common and most significant?
A
- Simple wedge (compression) fracture (MC by far)
- Bilateral interfacetal dislocation
- Flexion teardrop fracture (most significant by far)
- Clay shoveler’s fracture
- Anterior subluxation
- Dens fracture
16
Q
Traumas associated with hyperflexion and rotation injuries
A
Occurs along the same side as rotation
- Unilateral interfacetal dislocation
- Unilateral interfacetal fracture–dislocation
17
Q
Traumas associated with hyperextension injuries
A
- Avulsion of the anterior tubercle of C1 (rare)
- Hyperextension fracture-dislocation
- Hyperextension dislocation
- Posterior arch fracture of C1
- Extension tear drop fracture
- Hangman’s Fracture
- Lamina fracture
- Dens fracture
18
Q
Traumas associated with hyperextension-rotation injuries
A
- Pillar fracture
- Pedicolaminar fracture
19
Q
Traumas associated with Vertical compression forces
-Can neurologic problems arise from this type of trauma?
A
- Jefferson’s Fracture of C1
- Burst fracture of the lower cervical spine
- YES, these types of injuries may cause paraplegia or quadriplegia
20
Q
Traumas associated with Lateral flexion injuries
A
- Unilateral fracture, lateral mass of C1
- Transverse process fracture
- Uncinate process fracture
21
Q
Most common locations for spinal trauma
- How common is spinal cord injuries?
- Where is the spine is neurologic injury most common?
A
C1-C2, C5-C7, T12-L1
- Spinal cord injuries = 10-14% overall
- Neurologic injury = 40% cervicals
22
Q
Correct order for the Davis Series for the Cervical Spine
-Which film is used to rule out 90% of spinal trauma to the cervicals?
A
7 views (least to most invasive)
1) Lateral (90% of spinal trauma will be seen here)
2) A-P Open Mouth
3) A-P Cervical
4-5) Left and Right Obliques
6-7) Flexion and Extension
8) Swimmers (OPTIONAL)
23
Q
Why is this film not an acceptable lateral cervical film for the Davis series?
A
Does NOT show base of occiput to the top of T1
-If unable to get C7-T1 on the lateral film, should do a Swimmers view
24
Q
Most significant finding
A
Increased Retropharyngeal Space
( >7 mm is abnormal)
-Many causes including intubation, fracture, infection, SOL, etc.
25
What is the primary function for obtaining these views?
Check for instability of the cervical spine and increased ADI
-Very invasive, which is why it's done last
26
What is this?
Denis 3 Column Theory of Stability
- \>1 column disrupted = Unstable
- 1 column disrupted only = Stable
27
What abnormal soft tissues can let us know if a fracture of the cervical spine has occured?
- Retropharyngeal space ( \>7 mm)
- Retrotracheal space ( \>22 mm)
- Pre vertebral fat stripe (VERY subtle finding)
- Tracheal air shadow (should always be present)
28
Pathology
Increased Retrotracheal Space ( \>22 mm)
29
T/F The retrotracheal space should never exceed 14 mm in children younger than 15
True
30
What abnormal vertebral aligment are signs of spinal trauma
- Loss of lordosis
- Acute kyphotic angulation
- Widened interspinous spaces
- Vertebral rotation
- Torticollis
31
Findings
- Widening of the interspinous distance (Fanning)
- Loss of parallelism between facet joints
- Horizontal displacement \> 3.5 mm
- Angular displacement (sagittal plane rotation) \> 11 degrees compared with adjacent interspaces
Dx: Sprain/Strain of the cervical spine consistent with a flexion/extension mechanism of injury (Whiplash)
32
Pathology
Whiplash
33
Pathology
-How long would it take this injury to heal
Internal Decapitation
- normal spinal fracture healing is 3-6 months
- this injury is almost always fatal
+notice the increased ADI, increased Occipital-Atlas articulation, and the intubation tube causing an increase RPI
34
Pathology
-What type of injury mechanism can cause this?
Posterior Arch Fracture of C1
-Hyperextension mechanism
35
Pathology
Agenesis of the posterior arch of C1
- NORMAL VARIANT
- Note megaspinous sign of C2
- DDX Posteiror arch fracture
36
Pathology
-How extensive is the myelopathy associated with this condition?
Posterior Arch fracture of C1
-Does NOT cause myelopathy because the fracture will increase the size of the sagittal canal which if anything takes less pressure of the cord
37
Is this a Posterior Arch Fracture of C1?
-Why or why not?
NO! This is a Jefferson Fracture (of C1)
- a.k.a. Burst fracture of C1
- Jefferson Fracture and Posterior arch fracture of C1 look the same on a Lateral film. Need the CT or APOM to help DDX
38
Pathology
-What type of mechanism of injury is associated with this?
Jefferson Fracture of C1
- a.k.a Burst fracture of C1
- Axial compression mechanism
+ "Over Hang Sign" = Jefferson Fracture
39
In order for a Jefferson Fracture to be considered unstable, the lateral masses of C1 must not extend larger than ____ mm. What ligament helps to stabilize the lateral masses of C1?
Under 7 mm = Stable
- Transverse Atlantal Ligament
- \> 7 mm indicates a tear in the TAL making it unstable
40
Tiny fractures often obscured on plain X-ray but may become more apparent on advanced imaging like CT
Occult Fractures
41
T/F The TAL is more likely to shear off the odontoid than rupture secondary to trauma
True
-TAL is one of the strongest ligaments in the body
42
If an increased ADI is noticed on a lateral plain film, what 3 conditions are the most likely culprit in order?
1) RA
2) RA variant (AS, Reiters, etc.)
3) Trauma
- Increased ADI = \>3 mm in adults and \>5 mm in children
43
Pathology
None
- Congenital variant (Accessory ossicle of C1)
- DDX Avulsion fracture of the anterior tubercle of C1 (RARE)
+Notice how the cortex around the ossicle is well corticated = old injury/congenital variant
44
Etiology factors of an Increased ADI
- Normal variant (RARE)
- Trauma (RARE)
- Down's Syndrome (ligamentous instability)
- Major upper cervical anomalies (Klippel-Feil)
- Inflammatory arthopathies (RA = #1)
45
If an enlarged ADI is suspected, how do we determine if the area if stable or not?
Flexion/Extension X-rays
- Flexion is best for evaluating the ADI
- Neutral may show a subtle anteriority for the spinolaminar line of C1
46
Pathology
Increased ADI
47
Pathology
Type II Odontoid Fracture
- MC injury at C2
- MC type of odontoid fracture
48
Pathology
Type II Odontoid Fracture
- Watch out for the Mach Effect
- Advanced imaging like CT would confirm DX
49
Pathology
None
- Normal congenital variant Os Odontoideum
- Well corticated bone with no pain or history of trauma
- DDX Type II Odontoid fracture
50
Which types of odontoid fractures are stable and/or unstable?
Type I = Stable (rare)
Type II = Unstable (MC)
Type III = Can be either stable or unstable
51
Pathology
Type 1 Odontoid Fracture
- Rare, but stable
- DDX Os Terminale
- Fragment is irregular and top of dens is not uniformly corticated
52
What causes a type 1 odontoid fracture?
The avulsion of the tip results from a distraction caused by the apical and alar ligaments
53
30 year old male who came in complaining of upper neck pain that started after his car accident yesterday (being rear ended).
-Pathology
None seen on this view
- Patient has a normal Os terminale that would produce no signs or symptoms
- Well corticated structures rules out odontoid fractures
54
T/F Most os odontoideum are old ununited dens fractures
True
55
Pathology
Type III Odontoid Fracture
- Unstable
- Best seen on lateral plain film or with advanced imaging
56
Pathology
-What radiographic image is disrupted?
Type III Odontoid Fracture
-Harris' ring is disrupted
Disrupted Harris' Ring = Type III Odontoid Fracture
57
Pathology
Type III Odontoid Fracture
58
Pathology
-What mechanism of injury is associated with this?
Hangmans Fracture
- Bilateral pedicle fracture of C2 with anterior displacement of C2
- Associated with hyperextension injury
59
Pathology
-What other fracture can occur from the same mechanism of trauma that causes this fracture?
Hangmans Fracture
-May also see posterior arch fracture of atlas since that is also caused by a hyperextension injury
60
Where in the spine is the only place where a one time trauma can produce a spondylolisthesis?
-What neurologic problems associated with this type of fracture?
C2
- Hangmans Fracture
- Almost no neurologic problems since the fracture will cause an increase in the sagittal canal
61
Acute trauma present?
No!
- Nonunion Hangmans Fracture
- Well corticated bone indicated a nonacute injury
62
Pathology
Compression Fracture of C5
- Decreased height in the Anterior 1-2/3 of the vertebral body
- Superior endplate is most commonly affected
-
63
Pathology
-What mechanism of injury is most likely to cause this?
Compression Fracture of C5
-Flexion injury
STABLE!!!
64
Why are compression fractures most common in the anterior 1-2/3 of the vertebral body?
Cortical trabeculation of the vertebral body is less evident in the anterior 1-2/3 of the vertebral body
-Figure B
65
Helpful "clues" to determine old vs. new fractures
- Degenerative changes = old or new
- Intact cortex = old
- Cortical disruption = new
- Blurry/Hazy endplates = new
- Fracture line = new
- Line of impaction = new
- Step defect = new
66
Old or new fracture?
New
- Decreased intensity on T1 (less marrow)
- Increased intensity on T2 (lots of fluid/edema)
67
Old or new injury?
New
-Increased signal on bone scan indicates increased vascular flow consistent with edema
68
What radiographic signs are evident?
-What is the Dx?
Step defect
Zone of impaction (superior endplate)
-Acute Compression Fracture of L4
69
Pathology
None
Limbus Vertebrae
-Normal variant, especially in pediatrics
70
A faint black line is found traveling through the body of C2 to separate the dens from the rest of the body on the lateral cervical film of a 1 month old baby. What is the most likely pathology?
None
- Faint line is NOT a Type III odontoid fracture.
- Faint line is present because C2 has not fully ossified yet and the cartilage between the ossified bones does not absorb as much X-ray as the developed bones do.
71
Pathology
-What type of mechanism of injury is most indicated?
Burst Fracture of C5
-Axial compressive forces
-
72
T/F Burst fractures are generally stable and seldom present with neurologic compromise
FALSE.
- Unstable because the vertebrae is blown apart
- Neurologic compromise is likely because fragments can affect the cord (myelopathy) or nerve roots (neuropathy)
73
What activity is the most likely cause of an axial compression mechanism type of fracture?
Diving into a shallow pool/water
74
Pathology
Burst Fracture
- Flatened central body
- Vertical splitting (invagination) of the vertebral body
- Increased sagittal diameter
-
75
Pathology
Burst Fracture
76
Pathology
Cervical Burst Fracture
77
Patients presents with severe neurologic compromise in all his extremities
- X-ray was negative
- What should we do next?
Given neurologic problems, further imaging is needed (CT or MRI) to rule out other complications
-Problem is clear as day with CT
78
Pathology
Spinal Cord Transection
79
Pathology
-What mechanism of injury is associated with this?
Unilateral Facet Dislocation
- Flexion and rotation injury
- Anterior body displacement 25%
- Decreased laminar length
- Spinous rotation to the side of dislocation
80
Radiographic Sign
-What pathology is indicated?
Bow Tie Sign
-Non-superimposed articular pillars of the involved segment
Dx: Unilateral facet dislocation
81
T/F People with unilateral facet dislocations can not turn their head to the side of injury. The affected side is however mechanically stable
True
82
What film view is best utilized to confirm a diagnosis of unilateral facet dislocation?
Obliques
-No IVF seen at the location of the dislocation
83
Pathology
Unilateral Facet Dislocation at C6
- Short lamina
- Bow Tie Sign
- Anterior displacement of C6 to C7 by 25%
84
Radiographic Sign
-What pathology is indicated?
Inverted Hamburger sign (seen only on Axial CT)
-Dx: Unilateral facet dislocation
85
Pathology
-What mechanism of injury is most indicated?
Bilateral Facet Dislocation
-Hyperflexion mechanism
\*C4-C7 most commonly\*
-Anterior displacement by \> 50%
86
Is this a unilateral facet dislocation?
No!
- No Bow Tie Sign
- Anterior displacement is NOT 25%
- Regular length lamina
Rules out Unilateral Facet dislocation
+++Dx: Bilateral Fecet Dislocation
87
Radiographic signs of Bilateral facet dislocation
- Anterior displacement of vertebral body \> 50%
- Perched facets (incomplete bilateral facet dislocation)
- Interlocking facets (complete facet dislocation)
- Widened interspinous space
88
Pathology
Complete Bilateral Facet Dislocation
89
Pathology
Bilateral Facet Dislocation
90
T/F Bilateral Facet Dislocations are likely to present with neurologic problems
True
-Decrease in the sagittal canal
91
Radiographic sign
-What pathology is indicated?
Bilateral Inverted Hamburger Sign
-Dx: Bilateral Facet Dislocation
92
Most severe injury that can occur to the cervical spine
Flexion Tear Drop Fracture
93
Pathology
Flexion Tear Drop Fracture
- Triangular fragment at the anterior-inferior part of the body
- Facets are fully subluxated
- Leads to full paralysis or death
94
Pathology
Flexion Tear Drop Fracture
95
T/F Tear drop fractures and burst fractures appear so similar on X-ray. The major difference will be that tear drop fractures will produce tremendous neurologic problems while burst fractures will sometimes produce problems
True
-Tear drop injury = fully paralysis or death
96
Pathology
-What mechanism of injury is most likely to cause this?
Extension Teardrop Fracture
- Extension mechanism
- Triangular fragment at the anterior inferior aspect of the vertebrae
- Unstable
97
Patient walks into your office complaing of severe neck pain after slipping in his bathroom and hitting his chin on the sink. Your colleague thinks the patient has a flexion tear drop injury and orders a CT. What is the Diagnosis?
Extension Teardrop Fracture
-Wrong location and lack of neurologic problems to be Flexion tear drop fracture (would be at C5/C6 with either full paralysis or death)
98
What ligament becomes buckled following a extension teardrop fracture?
Ligamentum Flavum
99
Pathology
Extension Teardrop Fracture
- Triangular bone fragment anterior inferior aspect of C2
- Located at C2
- Increased RPI
- C2 posterior body line is posterior to C2
\*\*\* Classic Extension Teardrop Fracture\*\*\*
100
Pathology
-What mechanism of injury can cause this?
Clay Shoveler's Fracture
- Avulsion fracture of the spinous process
- Flexion injury mechanism
- MC at C7, then C6, then T1
101
Pathology
-Is this stable?
Clay Shoveler's Fracture
-Stable
102
Radiographic Sign
-What is the diagnosis?
Double Spinous Sign
-Clay Shoveler's Fracture
103
Pathology
None!
- Congenital Nonunion of the Secondary Growth Center of the Spinous Process
- Normal variant (well corticated margins rules out fracture)
104
Pathology
Clay Shoveler's Fracture
105
T/F All spinous fractures occur from a flexion mechanism type of trauma
FALSE
- Clay shoveler's fracture is the only one to occur due to a flexion mechanism
- Other spinous fractures can occur either due to a extension mechanism or from direct trauma
106
Spinous process fractures are most common in the mid \_\_\_\_\_\_\_\_\_, thoracic (except \_\_), and \_\_\_\_\_\_\_
Mid cervicals
T1
Lumbars
107
Pathology
-What mechanism of injury most likely caused this?
Laminar Fractures
- Hyperextension
- MC in lower cervicals
- STABLE
108
Pathology
Lamina Fracture
109
Is this a Clay Shoveler's Fracture of Lamina Fracture?
Clay Shoveler's Fracture
-Lamina fracture would cause posterior displacement of the spinolaminar line
110
T/F Lateral flexion injuries (uncinate process, transverse process, and unilateral lateral mass of C1 fractures) are rare
True
111
T/F X-ray is the best tool to see articular pillar fractures
FALSE
- Seeing a pillar fracture on X-ray is rare (A-P only)
- CT is the best choice
112
Pathology
-What mechanism of injury is associated with this pathology?
Whiplash
-Hyperflexion and Hyperextension
113
What Radiographic findings are seen on X-ray?
-What is the Dx?
- Widened interspinous spaces
- Widened facets
- Flex/Extension views to stress ligaments
Dx: Whiplash
114
Pathology
Whiplash
- Increased signal intensity on T2 indicates edema
- Edema is present in the posterior soft tissue structures and along the ligaments surrounding the vertebral bodies indicating soft tissue damage
115
Pathology
-What is the prognosis?
Occipital Atlantal Dislocation
- a.k.a. Internal Decapitation
- Almost always fatal
116
Is this a Flexion Teardrop Fracture?
NO! Extension Tear Drop Fracture
-Wrong segment
Flexion = C5-C6
Extension = C2-C3
