Ortho II

PA 532
 Synovial Fluid Analysis
Joint (arthrocentesis) or bursa
Indications: r/o infection in acute joint pain with
effusion and severe acute pain with joint ROM
Cell count
Crystals
Gout: (+) negatively birefringent, needle-shaped crystals
Pseudogout: (+)positively birefringent, rectangular-shaped
crystals
Culture, +/- sensitivity
Contraindications: Arthroplasty!
Measure Normal Non-Inflammatory Inflammatory Purulent
Volume (mL) <3.5 Often >3.5 Often >3.5 Often > 3.5

Clarity Transparent Transparent Translucent to Opaque Opaque

Color Clear Yellow Yellow to opalescent Yellow to green

WBC (per <200 <2,000 2,000-75,000 >100,000

mcL)
PMN Lymph <25% <25% 50%+ 75%+

Culture Negative Negative Negative Positive

DDX OA, Trauma, OCD, RA, Gout, Pseudogout, Pyogenic

Osteochondromatosis, Reactive arthritis, bacterial
Neuropathic Anklylosing infection
arthropathy, spondylitis, Rheumatic
inflammation, fever, TB
Hypertrophic
osteoarthropathy,
pigmented
villonodular synovitis
Bone Anatomy & Fracture Terminology
Review
Location
Epiphyseal
Metaphyseal
Diaphyseal
Skin integrity
Opened
Closed
oDisplacement of
Fragments
Nondisplaced
Displaced
Angulated
Distracted
 Fracture Terminology Review
Orientation/Extent Fx line
Transverse
Oblique
Need to be able
Spiral
to describe a
Comminuted
Intra-articular fracture
Torus accurately and
Compression concisely!
Greenstick
Pathologic
 CT vs MRI for MSK
CT scan and MRI display differences in tissue density, visualize entire
circumference and internal matrix of bone.
Indicated:
Bone injury not seen on xray
Injuries of joints, and soft tissues such as cartilage, muscles, and tendons
Inflammatory conditions of the bone (E.g. infection, tumors, etc)
Conventional radiographs first line for evaluating most injuries and
arthritis
CT
Bone detail: extent and severity of fracture
Fracture fragment evaluation
MRI
Occult fracture evaluation
Tumor evaluation
Soft tissue injuries ligaments, meniscus tears, rotator cuff problems, etc.
MRI: T1 & T2 Weighted Images

T1 T2
Radiographic Findings Of Selected
Orthopedic Conditions
 How to Order Xrays:

Always order at
least 2 views!

Weightbearing
films for OA

Ex: AP, Lateral &

Oblique views of the
left ankle, r/o distal
fibula fracture
Normal Knee
Stress Fracture
Pathologic Fracture
Non-union
Malunion
Gout
Chondrocalcinosis (CPPD)
OA - Knee
OA Hip
 OA - Ankle

Normal OA
RA
 OA vs RA Radiographically
OA RA
Degenerative/wear and Proximal joints of hands
tear and wrists
CMC, MCP, PIP
Hips, knees, hands
Bilateral and symmetrical
Subchondral sclerosis
Joint erosion
Subchondral cysts Joint space narrowing
Joint space narrowing Eventual fusion
Osteophytes Early: soft tissue swelling
and osteoporosis
Late: ulnar deviation at
MCP joints, subluxation of
MCP joints
Avascular Necrosis
AVN:
- Bone death leading to
collapse of the
affected bone
- Usually involves bone
with inherent poor
blood flow:
scaphoid, talus,
femoral head, etc
Osteochondritis Dessicans
Septic Arthritis
Destruction of:
Articular cartilage
Long, contiguous
segments of
adjacent articular
cortex
Rapid
Charcot
 Osteomyelitis

Focal cortical bone

destruction with
new periosteal
bone formation
Spondylolysis: Scottie Dog Sign
 Spondylolisthesis

Degenerative
Ankylosing Spondylitis

Bamboo Spine
Burst Fracture
Jefferson Fracture
Hangmans Fracture
Clay-Shovelers Fracture
Degenerative Disc Disease
Herniated vs Bulging Discs
Scoliosis
Femoral Neck Stress Fracture
Femoral Neck Stress Fracture
Femoral Neck Stress Fracture
Lisfranc Fracture
Jones Fracture
Jones Fracture & Avulsion Fracture
5th Metatarsal Base Fracture
Weber A Fibula Fracture
Weber B Fibula Fracture
Weber C Fibula Fracture
Bimalleolar Fracture
The rest of the story
Maissoneuve Fracture
Pes Cavus & Pes Planus
Hallux Valgus
Patellar Tendon Rupture: Patella Alta
Tibial Plateau Fracture
? Fracture
? Fracture
Smith & Colles
? Fracture
 ? Fracture
Snuff Box Tenderness

Immobilize & Refer

Radial Head Fracture
Shoulder Dislocation
Hill Sachs Lesion
AC Separations
Torus/Buckle Fracture
Greenstick Fracture
Salter-Harris Classifcation
Salter-Harris Classification
Slipped Capital Femoral Epiphysis
Avascular Necrosis of Proximal Femur
(Legg-Calve-Perthes Disease)
Accessory Bones

Smooth &
well rounded
 FYI
Medpix
Wheelessonline.com
Rheumatology Diagnostic Studies

PA 532
 Antibodies
Immunoglobulins on surface of B lymphocytes
IgG, IgM, IgE, IgA, IgD
Produced in response to a foreign protein or
substance within the body or randomly
 Autoantibodies
Antibodies manufactured by the immune
system directed against one or more of the
individual's own proteins
Usually a component of a cell
i.e. mitochondria, nucleus, centromere, ribonuclear
protein, histones, core proteins, DNA
 Autoantibodies
Indirect immunofluorescence assays identify
autoantibodies reactive with antigens in
particular tissues or subcellular compartments
(e.g., nuclear antigens)
Fixed tissue samples/cells are overlaid with
patient sera and then washed.
Detect autoantibodies that are bound to sample
with fluorescein-labeled antiserum to Ig
 Autoantibodies
Directed to:
Nuclear material antinuclear antibodies
(ANA)
Cytoplasmic material anticytoplasmic
antibodies
Membrane
Mixed Connective Tissue Disorders
Patients with overlapping s/s with
rheumatologic disorders, ex:
SLE, scleroderma, inflammatory myopathy
SLE w/ Raynaud, polyarthritis, myositis,
pulmonary HTN
RA & SLE or SLE & scleroderma
Can also be hereditary
Osteogenesis imperfecta, Ehlers-Danlos
Syndrome, Marfan Syndrome
 Common ANA and Autoimmune
Disease
ANA Screen Autoimmune Disease
Anti-Extractable Nuclear Antigen (ENA) SLE, MCTD
- Anti-ribonucleoprotein (RNP) MCTD, SLE, PSS
- Anti-sm or Anti-Smith SLE
- Anti-Jo-1(antihistidyl transfer synthase) Polymyositis, dermatomyositis
- Anti-SS-A (anti-Ro) and anti-SS-B (anti- Sjorgren syndrome, SLE (ANA negative)
LA)
- Anti-scleroderma- 70 PSS
Anti-native double-stranded DNA (dsDNA) SLE
Anti-single-stranded DNA (ssDNA) SLE
Anti-centromere PSS, SLE
 Anticytoplasmic Antibodies Diseases
Antimitochondrial antibodies (AMA) Primary Biliary Cirrhosis
Antineutrophil Cytoplasmic Antibody Granulomatosis with Polyangitis, Churg-
(ANCA, C-ANCA, P-ANCA) Strauss Syndrome, CF
P-ANCA: Ulcerative colitis, PSC
Antimiscrosomal
-Antithyroid Hashimoto thyroiditis
- Anti Liver Kidney Microsomal Autoimmune hepatitis (Anti-LKM-1)
Antibody (Anti-LKM)
Antithyroid Antibodies Hashimotos thyroiditis, Graves disease,
- Antithyroglobulin lymphocytic thyroiditis in children
- Antithyroid peroxidase antibody (Anti-
TPO)
Antiribosomal SLE
Anti-RNA Scleroderma
Anti-cardioplin antibodies (ACA) SLE (with high risk for antiphospholipid
antibody syndrome)
Anti smooth muscle antibody (A-SMA, aka Autoimmune hepatitis, PSC
Antiactin antibody)
 Cell Membrane Antibodies
Cell Membrane Antibodies Disease
Antiglomerular Basement Membrane Goodpasture syndrome (autoimmune-
Antibody induced nephritis)
 Antinuclear Antibody (ANA)
The most commonly performed screening test in
patients suspected of connective tissue disease
Serologic hallmarks for systemic or organ-specific
autoimmune disease
Most common circulating autoantibody in many
autoimmune diseases (SLE, autoimmune hepatitis)
Results given as a titer and type of
immunofluorescence pattern
ANA titer is positive if 1:80 or greater
Pattern: homogeneous, outline/rim, speckled, nucleolar
ANA Patterns & Associations

In general,
there is a
poor
correlation
between the
pattern &
underlying
disease
 ANA
Most sensitive laboratory test for SLE
Best single test to rule out SLE*
ANA is first line screen
95% sensitive, 49% specific
(+) ANA for SLE is usually titer of 1:160
SLE is a disease of overproduction of
autoantibodies to nuclear antigens
 SLE
(+) ANA SLE
Other antibody studies must be done to confirm
dx and/or consideration of clinical symptoms
Other autoantibodies highly specific for SLE:
dsDNA (75% sensitive)
Anti-SM (25% sensitive)
What if ANA is (-) and SLE is suspected?
ANA negative SLEAnti-SSA
 Anti-DNA Antibody
Indications: diagnosis and follow-up of SLE
High titers are characteristic of SLE
> 200 IU/ml
Low-intermediate titers
chronic hepatitis, infectious mono, biliary cirrhosis,
other autoimmune/rheumatic disorders
Titer decreases with treatment of SLE
Titer increased with SLE exacerbations or onset
of GN
 Anti-DNA Antibody
Two types:
Anti-dsDNA: commonly found
Anti-ssDNA: less sensitive, less specific for SLE
These complexes induce the complement
system leading to local or systemic tissue
damage!
 Anticardiolipin Antibody
Some patients with SLE have this antibody
which puts them at risk for anti-phospholipid
syndrome
Anti-phospholipid syndrome antibodies include
anticardiolipin ab (40% SLE patients)
lupus anti-coagulant (50% SLE patients)
which prolongs PTT however not assoc w/ incr bleeding!
SLE pt w/Anticardiolipin ab + lupus anticoagulant =
risk for anti-phospholipid syndrome
 Anticardiolipin Antibody
Indications:
Venous and arterial thrombosis, neuropsychiatric
disorders, recurrent spontaneous abortion, and
thrombocytopenia
May also be found in drug induced lupus, acute
infection, and elderly persons, IgA, IgG, IgM
 Anti-Centromere Antibody
Subtype of antinuclear antibodies (ANA)
Used to support the diagnosis of CREST
syndrome
(+) in 90% CREST (limited disease scleroderma)
 Anti-ENA
Extractable Nuclear Antigens (ENA)
Consist of RNA and protein
Type of ANA
Useful in assisting diagnosis of SLE or mixed
connective tissue disease
Helps r/o other rheumatologic diseases
 Anti-ENA
Types of Anti-ENA
Anti-Smith (SM) antibody*
30% SLE
8% MCTD
Absent in other rheumatoid-collagen diseases
Anti-RNP (ribonucleoprotein) antibody*
100% MCTD
25% of SLE, discoid lupus and scleroderma
Anti-Jo-1 antibody
Autoimmune interstitial pulmonary fibrosis, polymyositis,
dermatomyositis
Anti-SSA & Anti-SSB used to dx Sjogren
 Antiglomerular Basement Membrane
Antibody
Detects presence of circulating GBM ab found
in autoimmune GN or lupus nephritis
Sample can be blood (circulating) or tissue
biopsy
Circulating blood is quicker and less invasive
 Anti-SSA/SSB/SSC Antibody
Indications: Suspected Sjogren Syndrome (SS)
SSA(+): 60-70% pts w/ Sjogren
SSB(+): 50-60% pts w/ Sjogren
SSA (+) + SSB(+) = Sjogren diagnosis
SSC (+): 75% pts w/RA or RA assoc. Sjogren
SSA & SSB almost never found in RA assoc. Sjogren
 Anti-SSA/SSB/SSC Antibody
Indications: SLE
SSA (+) in 25% of pts w/ SLE
Most patients with ANA-negative SLE will
have (+)SSA
 Anti-SCL-70
Indications: Suspected scleroderma
(+) in 45% of patients with scleroderma
Does not differentiate limited vs diffuse
scleroderma
Also seen in
SLE, MCTD, Sjogren, Polymyositis, Rheumatoid
Arthritis
 Anti-mitochondrial (AMA)
Anti-cytoplasmic antibody directed against a
lipoprotein in the mitochondrial membrane
Useful in diagnosis of:
Primary biliary cirrhosis (+ in 94%)
Cholestasis, chronic and acute hepatitis,
extrahepatic obstruction
Also (+) in patients with autoimmune hepatitis
from SLE, scleroderma*
 Antineutrophil Cytoplasmic Antibody
(ANCA)
Indications: Suspected Granulomatosis w/
Polyangiitis
Two patterns
Cytoplasmic (C-ANCA)
Perinuclear (P-ANCA)
Increased levels in many diseases, but commonly
associated with granulomatosis with polyangiitis
P-ANCA is associated with ulcerative colitis and
primary sclerosing cholangitis
 Anti-Smooth-Muscle-Antibody
Anticytoplasmic antibody
A.K.A. anti-actin antibody
(+) in patients with autoimmune hepatitis
 HLA-B27
Human Lymphocyte antigen B-27
Normally occurs: 8-10% Whites, 2% African
Americans
Higher occurrence in some Native American &
Eskimo
Indications: Support diagnosis of certain
diseases (AS, reactive arthritis)
Also helpful in paternity testing as well as
checking histocompatibility in a tissue transplant
 HLA-B27
Positive in:
90% AS patients
75% Reactive arthritis patients
50% Psoriatic and inflammatory bowel disease
patients who also have sacroiliitis
Example of genes + environment
Risk of developing reactive arthritis is
0.2% general population
2% in HLA-B27 patients
20% in HLA-B27 pts infected with Salmonella, Shigella or
enteric organisms
 Rheumatoid Factor (RF)
Indications: Suspected RA or rheumatologic
disease
The titer is positive if > 1:80
Positive in 80% of patients with RA
Sensitivity of 66.3%, Specificity of 82.1%
Titers <1:80
SLE, scleroderma, Sjogren syndrome, other
rheumatologic diseases
Does not disappear with decreasing sx
Negative does not rule out RA
 Anti-CCP Antibody
Anticyclic-citrullinated peptide antibody
Indications: Unexplained joint inflammation
Especially if after (-) RF with suspicion for RA
Sensitivity 67.5%, Specificity 99.3% for RA
This test has a higher specificity than RF for RA
 Anti-CCP Antibody
Anti-cyclic-citrullinated-peptide
Specific for rheumatoid arthritis, early in
course of disease
Which is important for treatment
Marker for disease progression
 CRP
Indications: Inflammatory illness
C- reactive protein
Protein made by the liver in response to inflammation
More sensitive (& faster) than ESR
For rheumatologic disorders this is used to
screen, or build a case for a diagnosis
Also used to detect bacterial infections, tissue
infarct (MI), risk of cardiovascular ischemic
events, etc.
Erythrocyte Sedimentation Rate (ESR)
Indications:
detection of acute or chronic inflammation,
infection, neoplasm, and tissue necrosis/infarction
Nonspecific
Vague symptoms or differentiation
Monitor therapy and progression
 Autoimmune Disease & Positive
Autoantibodies
SLE ANA, ds DNA, ss DNA, anti-SSA,
anti-cardioplin (ACA)
Sjogrens ANA, anti SSA, anti SSB
Scleroderma/CREST ANA, anti-Scl-70
Anti-centromere
MCTD ANA, anti-RNP, RF, ss DNA
Autoimmune Hepatitis ANA, Anti-LKM

Biliary Cirrhosis ANA, AntiLKM, AMA

RA RF, ANA, anti-CCP
 Diagnostic and Classification Criteria
and Other Resources
American College of Rheumatology
http://www.rheumatology.org/Practice/Clinic
al/Clinical_Support/

Lupus Foundation of America

http://lupus.bluestatedigital.com/video/entry/w
hy-lupus-is-a-cruel-mystery
Neurology Diagnostics I

PA 532
 Head Imaging Modalities

What is the study of choice in head trauma?

What are some reasons why this the study of

choice?
 Head Imaging Modalities
What is the study of choice for detecting and
staging intracranial & spinal cord abnormalities?

What is preferred for detecting calcifications in

lesions and cortical bone?
 CT Densities
White areas/hyperdense
Bleeding (high in protein)
Metal
Calcium (calcifications, bone)
Dark areas/hypodense
Fat usually not in the brain
Air sinuses
Water - CSF
 CT Densities
Gray Areas/Isodense
Normal brain
Some forms of protein
Subacute subdural hematoma
Brain Slices
 Evaluating the Head CT of an Acute
Trauma Patient
Bleeding
Location
Shape of the bleeding
Look for shift of midline structures
neurological emergency
Look for loss of normal tissue contrast
Tissue contrast is symmetric- normal head CT
Loss of distinction between gray and white
matter is a sign of severe brain edema and
has a poor prognosis
Evaluating Head CT
Weve come a long way since 1975!
Epidural vs Subdural Hematomas

CONVEX CONCAVE
Epidural Hematoma
Note the midline shift
and loss of normal
tissue contrast. Call
the neurosurgeon!

This takes significant

blunt head trauma & is
usually associated with
a skull fracture

The hemorrhage is in the epidural

space, between the skull and the dura.
The pattern of bleeding is CONVEX to
the brain, or a crescent-shaped
mass
Evaluating the Head CT of an Acute Trauma
Patient
Evaluating the Head CT of an Acute Trauma
Patient
Subdural Hematoma
Can be
caused by
minor
trauma in
an elderly
patient or
an MVA in
a younger
patient

The hemorrhage is between the dura and the arachnoid

membranes. The pattern of bleeding is CONCAVE to the
brain, or parallels the surface of the skull.
Chronic Subdural Hematoma

On your
differential
diagnosis for
subacute
confusion in
an older adult
R L
 Subarachnoid Hemorrhage

This can be traumatic,

but is more often the
result of a ruptured
aneurysm or AVM

The hemorrhage is in the subarachnoid

space between the pia and arachnoid
membranes
AVM
Intracerebral Hemorrhage
Can be due to trauma
or hemorrhagic stroke

The bleeding is encased in the

substance of the brain, often confined
to the area of a ruptured vessel
 Coup
Injuries at the point of impact
Shearing of small vessels
Contrecoup
Injuries at the opposite point of impact
Acceleration/deceleration injuries
both cause cerebral contusion/hemorrhage
 Cerebral Edema
Two types of edema:
Vasogenic - extracellular accumulation of fluid
Malignancy, infection
Predominantly affects white matter
Cytotoxic associated with cerebral ischemia
Cerebral ischemia
Affects both gray and white matter
Cerebral Edema
Cerebral Edema
 Stroke
CT is the initial study in acute stroke
Noncontrast CT
CT scan to differentiate ischemic infarct vs.
hemorrhagic
MRI used for both acute stroke and TIA
Becoming more widely used
Prefer diffusion-weighted MR
 Stroke
Ischemic stroke
CT may be normal for the 1st 12 hours
Infarcted portions of the brain appear
BLACK
Hemorrhagic stroke
About 15% of strokes
Bleeding areas appear WHITE
Ischemic Stroke
Ischemic Stroke
Ischemic Stroke
Hemorrhagic Stroke
 Hydrocephalus
Expansion of the ventricular system
Increased CSF due to:
Poor absorption
Restriction of outflow
Overproduction of CSF (rare)
Obstructive
Communicating (poor resorption)
Non-communicating (outflow restriction physical)
Normal-pressure Hydrocephalus (NPH):
Communicating type of hydrocephalus
Triad: Gait abnormalities, Dementia, Urinary Incont.
Onset age 50-70 yo
Normal Pressure Hydrocephalus

Normal NPH
MRI
Neurology Diagnostics II

PA 532
 Brain Tumors

MRI is diagnostic test of choice

CT replaces or is done in addition to MRI:
To detect bone or vascular involvement
To detect metastases to the skull
In an emergency situation (eg, an unstable patient
with a suspected hemorrhage)
In patients for whom MRI is contraindicated ex:
iron-containing implant (pace-maker)
Meningioma
Brain Tumors
extra-axial mass
Brain Metastasis
Brain Metastases
Acoustic Neuroma
Acoustic Neuroma

Contrast MRI
MS
 MRI
Is
Study
Of
Choice
23 year-old female with progressive
weakness and visual disturbances
EEG
 EEG
Important in diagnosing epilepsy, however
cannot be used alone to make the diagnosis.
Limitations
EEG patterns can be caused by a variety of different
neurologic diseases
Not all cases of brain disease are associated with EEG
abnormalities
Many disease cause more than one EEG pattern
Intermittent EEG changes may not appear
EEG can be abnormal in persons without disease
EEG Results
 Evaluating Seizure in Adults
MRI to rule out brain lesion
Labs
R/O Metabolic or toxic cause (CMP, toxicology screen)
Serum Prolactin level - may rise shortly after generalized
tonic-clonic seizures and some partial seizures if 10-20
minutes after an event and compared to baseline 6 hours
later.
Lumbar puncture if infection is suspected
If a space occupying lesion is suspected (causing focal
neurologic deficit, seizure or papilledema) a CT should be
done BEFORE the LP d/t risk of brain herniation
A normal EEG does not rule out epilepsy
 Nerve Conduction Studies
Focal and generalized disorders of peripheral
nerves
Aid in the differentiation of primary nerve and
muscle disorders
Classify peripheral nerve conduction
abnormalities due to:
Axonal degeneration, demyelination and
conduction block
Follow up to determine prognosis
Nerve Conduction Study
 Electromyography (EMG)
Clinical study of the electrical activity of
muscle fibers individually and collectively
Lumbar Puncture
 LP: Indications
Urgent
Suspected CNS infections (meningitis)
Suspected subarachnoid hemorrhage (SAH) in
patients with a negative CT scan
Nonurgent
Pseudotumor cerebri
NPH
CNS syphilis
MS
 LP: Contraindications
Increased intracranial pressure
Patients with altered level of consciousness, focal
neurologic deficit, new-onset seizure, papilledema
or immunocompromised
Imaging needs to be done first to decrease risk of brain
herniation
Thrombocytopenia or bleeding disorders
Risk of post-LP subdural/epidural hematoma
Order Platelet count, INR, PTT
Platelet count <20,000/uL LP is contraindicated
(protocols vary by institution)
Suspected spinal epidural abscess
 Potential Complications
Post-LP headache* (10-30% of patients)
Infection
Bleeding
Radicular pain or numbness, back pain (may need to
image first)
Cerebral herniation*
CT first r/o elevated ICP, mass (last slide)
Unless bacterial meningitis is suspected do LP first
unless:
Symptoms (last slide) of increased ICP, in pt with suspected
meningitis, then give ABX prior to imaging
 Normal Composition
Pressure: 50-180 mmH20
RBC: None
WBC: Lymphs 60-70%, Monocytes 30-50%,
Neutrophils none
C & S: No growth
Protein: 15-50 mg/dL
Glucose: 40-70 mg/dL
Lactate 10-20 md/dL
Normals: Protein: 15-50 mg/DL; Glucose: 40-70 mg/dL
 PET Scan
Positron Emission Tomography
Used for evaluation of the brain anatomy &
physiology
Radioactive chemicals are given IV then detected
during CT scan to demonstrate metabolic process
of cells/blood flow (physiology)
Brain PET most commonly uses radioactive
fluorine (FDG)
 PET Scan
Increased activity:
Epilepsy, Parkinson disease, Huntington
disease.
Decreased activity:
Alzheimer disease, brain
trauma/hemorrhage.
Now, you try
Q: Where is the
bleeding?
Classic Triad: gait
disturbance,
urinary
incontinence, and
dementia
Radiology for PA
Students
Part IV: Orthopedic
Imaging
kgraham@uwlax.edu
 Objectives
Determine the most appropriate imaging study
to order for a particular musculoskeletal or
neurological complaint
Use appropriate terminology to describe
fractures, subluxations, and dislocations
Recognize common adult and pediatric fractures
Describe the radiographic features of OA, RA,
and osteomyelitis
Identify normal anatomy on C-spine radiographs
Determine when imaging for back pain is
appropriate
NOTE: The objective of this
lecture is not to review
normal skeletal anatomy.
You should be able to identify
normal skeletal anatomy on
conventional radiographs
based on your recent
anatomy course. Normal
bone anatomy can be
reviewed in your radiology
and anatomy texts.
Skeletal Imaging
Conventional radiographs are first line for
evaluating most injuries and arthritis
CT
Bone detail: extent and severity of fracture
Fracture fragment evaluation
MRI
Occult fracture evaluation
Tumor evaluation
Soft tissue injuries ligaments, meniscus tears,
rotator cuff problems, etc.
3D Reformatted CT
Skeletal Imaging
Bone Scan
Also called bone scintigraphy
Involves the IV injection of a radioactive tracer that
accumulates in bone that is undergoing rapid turnover
or growth
Has been replaced by MRI for many indications
Still used to screen for stress fractures, osteomyelitis,
and skeletal metastases
Ultrasound
Newer applications include evaluating superficial
structures (tendons, muscles, soft tissue masses) and
guiding injections
 Bone Scans

Patient with
metastases of
breast carcinoma to
the spine and pelvis

Patient with risk factors

for osteomyelitis who
presented with pain
and swelling in the right
2nd toe
Proper Radiographic Imaging
Rule of 2s
Always use at least 2 views
Look at the joints above and
below a fx
Look at 2 sides in children with
open epiphyses
You dont need to memorize
what views are indicated for
what areas, but you need to
give good history to the
technologist!
Viewing the Bone Radiograph
Look at each bone
Look for smooth contours
Look for any abnormal lucencies or opacities
Fracture lines are usually lucent
Look at each joint
Check for asymmetry or joint space narrowing
Look at the soft tissues
 What is to follow.

This module has lots of TERMINOLOGY.

Why? Because suspected fractures are
the most common reason for ordering
skeletal radiographs, and the primary care
PA needs to understand the basic
terminology to communicate effectively.
Fracture Terminology:
Simple/closed fracture

Important note: not all

fractures are visible on
initial radiographs! Subtle
fractures may become
visible 7-10 days after the
injury.

Closed skin is intact

Simple 2 fracture fragments
Radiograph A is the initial film done following the wrist
injury. The arrows point to a simple longitudinal fx of the
distal radius. Film B was taken a week later after fixation
pins were placed. The fx line is much more visible now.
Fracture Terminology:
Compound (open) fracture
These fractures are at high
risk for osteomyelitis

Skin is
penetrated
This is an open tib-fib fx.
Note that the fractured
bone breaks the soft
tissue plane.
Fracture Terminology:
Comminuted (complex) fracture

Comminuted
forearm
fracture

More than 2 bone

fragments
Fracture Terminology:
Fracture line descriptions
The arrow is pointing
to a transverse
fracture of the ulna

Figure 22-7
Fracture Terminology:
Fracture line descriptions

The arrows are

pointing to an oblique
(or diagonal) fracture
of the 1st metacarpal
base
The arrow is pointing
to an oblique fracture
of the ulna

Figure 22-7
Fracture Terminology:
Fracture line descriptions
A spiral fx
in a child
who is not
walking is
suspicious
for child
abuse

Spiral fractures are caused by rotational forces and

are usually seen in children
Spiral fractures of
the fibula

Figure 22-7
Fracture Terminology:
Angulation

Terms like dorsal, radial, ulnar, valgus, and varus are

also used to describe the direction of the angulation.
Fracture Terminology:
Displacement
Displacement is
named according to
the distal fragment.
Can be full
displacement or side-
to-side movement of
fragments.
Q: So how would
we describe this
fracture?

A: A medially
displaced
transverse
midshaft fracture of
the humerus
Fracture Terminology:
Distraction & Overriding

Fragments have Also called

been pulled apart shortening
Fracture Terminology:
Impaction

Fragments have been

driven together

This drawing
depicts an
impacted femoral
neck fx
Fracture Terminology:
Stress Fracture
Note that stress
fractures are opaque
Summation of rather than lucent
microfractures caused
by unusual or excess
stress; frequently seen
in athletes

The tibia is a
common site of
stress fx in all age
groups
Fracture Terminology:
Pathologic Fracture
Fracture through a bone
abnormality, benign or
malignant; can occur
with minimal or no
trauma

This patient had

metastatic renal cell
carcinoma with a
pathologic femur fx
This patient also had
metastatic renal cell
carcinoma, with a
pathologic humerus fx

Figure 21-27
Fracture Terminology:
Avulsion Fracture
Fracture of a bony fragment that is produced by
the pull of a ligamentous or tendinous attachment

This is an
avulsion fx
of the middle
phalanx
Fracture Terminology:
Avulsion Fracture

This is an
avulsion fx
of the knee
due to an
ACL tear
Pediatric Fractures:
Normal physis
Metaphysis

Physis (growth
plate) bone
formation occurs on
both sides; this is
the weakest part of
a growing bone

Epiphysis

Eventually, the epiphysis &

metaphysis will fuse as the The bone
physis closes (during shaft is the
adolescence) diaphysis
Pediatric Fractures:
Salter-Harris Fractures

Black line indicates the fracture

Pediatric Fractures:
Salter-Harris Fractures

Type I = S = Separated
Type II = A = Above epiphysis
Type III = L = Lower (epiphysis)
Type IV = T = Through
Type V = R = Rammed
Pediatric Fractures:
Salter-Harris Fractures

Type III

Type II

Figures 22-15, 16
Pediatric Fractures:
Salter-Harris Fractures Type IV

Type V

Figures 22-17,18
Pediatric Fractures:
Greenstick Fracture

Greenstick fractures are incomplete fractures in which

the bone bends like a twig and the cortex cracks
Pediatric Fractures:
Torus fracture
This is a torus
fracture of the
distal radius.
The arrow is
pointing to the
buckled
cortex.

Torus fractures (buckle fractures) are also incomplete

fractures. The buckled cortex creates a bump without
an obvious fracture line.
Fracture Healing:
Callus formation
Notice that the fracture Q: Is this film
line is no longer clean from an adult
and lucent. There is or child?
some bony bridging of
the fracture line callus
formation.

It is important to remember that the rate at

which a fx heals is dependent on individualized
factors, including age, type of fracture,
adequacy of immobilization, and nutritional
status
Fracture Healing:
Nonunion (nonhealing)
Causes of fx nonunion:
infection, inadequate
immobilization,
inadequate blood
supply, and inadequate
nutrition

Save this term for the

orthopedic surgeon!
Fracture Healing:
Malunion
Fx has healed
in an
unacceptable
position

In this healed forearm fx, the radius and ulna have

been fused by callus
 Common Fractures:
Scaphoid Fracture
Classic presentation: hx Most commonly fractured
of fall on an carpal bone have a high
outstretched hand suspicion for this!
(FOOSH) with pain in the
anatomic snuffbox

Order a
scaphoid
view
Common Fractures:
Scaphoid Fracture

5% of scaphoid
fractures have
complications
Nonunion
Osteoarthritis
Avascular necrosis
 Common Fractures:
Scaphoid Fracture

This scaphoid fx is
easily seen; but if you
do not see a fx initially, White arrow
order MRI or immobilize identifies an
ulnar
and obtain f/u films styloid
fracture
Always refer these to
ortho this one was
surgically repaired
Common Fractures:
Fracture of the
Colles Fracture distal radius
with dorsal
angulation of
the distal
fragment;
sometimes with
ulnar styloid fx

More common in
children and older
Another hyperextension
adults (scaphoid
injury FOOSH fractures are more
common in 15-40 y/o)
Common Fractures:
Colles Fracture

Surgical repair
Common Fractures: Injury fall on
the back of a
Smith Fracture flexed hand

Figure 22-22

The reverse of Colles:

fracture of the distal radius
with palmar angulation of the
distal fragment
 Common Fractures:
Radial Head Fracture

Easily missed on
radiograph: look for the
posterior fat-pad sign

Caused by a fall on an
outstretched arm or
direct blow to the elbow Most common elbow
fracture in adults
Figure 22-27. Fracture of radial head with joint effusion, frontal (A)
and lateral (B) views. Radial head fractures (closed white arrows) are
the most common fractures of the elbow in an adult. Look for fat
appearing as a crescentic lucency along the dorsal aspect of the distal
humerus (open white arrow) caused by intracapsular, extrasynovial fat
that is lifted away from the bone by swelling of the joint capsule due to a
traumatic hemarthrosis-the positive posterior fat-pad sign. Virtually all
studies of bones will include at least two views at 90 angles to each
other, called orthogonal views. Many protocols call for two additional
oblique views, which enable you to visualize more of the cortex in profile.
 Common Fractures:
Boxer Fracture

Fracture of the head of

the 5th metacarpal

Usually a result of
punching a solid object

Figure 22-24
Common Fractures:
Hip Fractures
There are more than 300,000
hip fx in US every year &
incidence is on the rise!
Risk factors
OSTEOPOROSIS (and all of
its risk factors)
Age (incidence doubles with
each decade beyond 50)
High energy trauma or
pathologic fractures in the
young
Common Fractures:
Hip Fractures
Most hip fractures are
in the femoral neck or
the intertrochanteric
region
Fx line may be
difficult to see in a
patient with
osteoporosis
AP Pelvis is the
best initial view to
look for hip
fractures

MRI is best
to detect
occult
fractures
Here, the left femoral neck
fracture cannot be seen on
the AP hip view

But it can be seen on MRI!

Examples of hip
hardware
Joint Injury Terminology:
Subluxation

Incomplete
loss of
contact
between
articular
surfaces

PIP subluxation
Joint Injury Terminology:
Dislocation

Complete
loss of
contact
between
articular
surfaces

PIP dislocation
 Joint Injury Terminology:
Dislocation
Dislocations
are described
by the
position of
the distal
bone(s)

Posterior elbow
dislocation
Extreme Example Bilateral Hip
Dislocation
This
would
require
violent
trauma,
such as
an MVA

Posterior
dislocation

Anterior
dislocation
Shoulder Dislocations are much
more common
The shoulder is a
highly mobile joint &
the most common
joint to dislocate
Most shoulder
dislocations (95%)
are anterior
Special views can be
ordered

Normal shoulder
Posterior shoulder Anterior shoulder
dislocation: humeral head dislocation: humeral head
might appear superior to appears inferior to glenoid
glenoid cavity on AP film cavity on AP film
Non-traumatic Skeletal
Pathology
 Osteoarthritis (OA)
Most common joint disease
Presents clinically as pain, deformity, &
limited ROM
Most common cause of disability after age
65
Almost all patients >65 will have
radiographic signs of OA (although not
necessarily clinical signs)
 Radiographic Signs of OA
Asymmetric joint space narrowing
Sclerotic bone changes (more dense)
Degenerative cysts (more lucent)
Osteophyte formation (bone spurs)
 Note the joint space
narrowing at the DIP
joints

The white arrow is

pointing to an
osteophyte

A: DIP, 1st
metacarpal-
Q: What joints are most carpal, hips,
commonly affected by OA? knees, & spine
Note the
medial joint
space
narrowing on
this left knee
radiograph.
This
asymmetric
joint space
narrowing is
typical for OA.
 Note the
asymmetric
joint space
narrowing and
sclerosis
around the
joint. The
arrow is
pointing to an
osteophyte.

Q: What is it?

Q: What is it?
Osteoarthritis of the
spine

Note the osteophyte,

sclerosis, and joint
space narrowing

Figure 24-7
 Rheumatoid Arthritis (RA)
Inflammatory arthritis
Joints can become painful, swollen,
deformed, with morning stiffness
Most commonly affects the MCP, wrist,
and PIP joints
DIP joints usually not involved
 Radiographic Signs of RA
Symmetric joint
space narrowing
Periarticular
osteopenia or
osteoporosis
Osseous erosions
MCP subluxation
(which causes the
ulnar deviation seen
clinically, a late
finding)
This is the classic look of severe RA
on radiograph of the hands, with MCP
subluxation and osteoporosis.
OA vs. RA
OA vs. RA
OA vs. RA
 Optional ReadingChapter 23
of Textbook
An approach to arthritis, covers other
types of arthritis such as
Gout
Calcium pyrophosphate deposition disease
Charcot arthropathy (neuropathic joint)
Psoriatic arthritis
 Bone Tumors

This is a
Sharply marginated lesions are malignancy, an
usually benign. This is an osteosarcoma of
enchondroma. the femur.
Bone Tumors
Which of these is probably cancer?
Bone Tumors

Metastatic lesions are far

more common than primary
bone tumors

Aggressive renal
cell carcinoma that
has metastasized to
the humerus
Osteomyelitis
Focal
destruction of
bone by
infection
Acquired by
hematogenous
spread,
contiguous
This is the classic lytic-sclerotic
spread, or direct look on conventional radiograph,
inoculation but this case has been developing
for a few months.
 Osteomyelitis
Osteomyelitis of
the 2nd metatarsal
in a diabetic

Findings on
conventional
radiograph will
not be seen for 10-
14 days, if then

Figure 21-25
 Osteomyelitis
Q: What imaging
modalities would be better
for diagnosing
osteomyelitis?

A: Bone scan or MRI

Osteomyelitis of the femur

The Spine
Q: Which of these is the most expensive?
Spine Imaging
Role of conventional radiograph
Initial screening for some spinal trauma and disease
Role of CT
Initial screening for patients with C-spine trauma in
many facilities, especially if the brain needs to be
evaluated anyway
Excellent for localizing fracture fragments
Role of MRI
In trauma: to look for spinal cord, disc, or ligament
injury
Study of choice for most diseases of the spine

Q: Which of these is the fastest?

 C-spine Imaging
50% of C-spine trauma is secondary to
MVA
There is no national standard protocol at
this time for C-spine trauma imaging
Some facilities still use a trauma series
(AP, lateral, open mouth radiographs) for
initial screening but many facilities are now
sending trauma patients straight to CT
>50% of fractures can be missed on
conventional radiograph
Open mouth or Odontoid view
Viewing the
lateral C-spine
film
Check for
alignment on
lateral view 3
imaginary contour
lines
Disruption
indicates bony or
ligamentous injury
Viewing the lateral C-spine Film
Visualize all 7 cervical
vertebrae and the C7-
T1 space
Check vertebral body
heights
Check disc space
heights
 A Few of the Common Cervical
Spine Fractures
Most cervical spine fractures occur between C5-
C7, followed by C1-C2
Teardrop fracture
Flexion injury
Hangman fracture
Extension injury
Fracture of the posterior elements of C2
Odontoid process fracture
Flexion or extension injury
More common in the elderly
T2 T1
Imaging for Back Pain
Acute back pain is the 2nd most common
complaint in primary care
90% will resolve without imaging or intervention
& often without a specific dx
The problem with imaging: most adults over 40
will have degenerative lumbar spine changes on
conventional radiograph and degenerative disc
changes on MRI. So how do we know if it has
anything to do with the pain?
Imaging for Back Pain
Most authorities suggest no imaging for 4-
6 weeks unless there are red flags
Red flags for early imaging
Severe, progressive neurologic deficit
Minor trauma in osteoporotic patients
Major trauma in all other patients
History of cancer or weight loss
Recent bacterial infection
Fever
Immune suppression
Compression fractures
May occur with
minimal stress in a
patient with
osteoporosis
Most frequently
involves middle-lower
thoracics and upper
lumbar
Major cause of
morbidity in the
geriatric population
Thats all for the spine. But remember, just as with
all bones, dont forget to look at more than 1 view!
A few notes about head
imaging
 Just FYI.
because conventional radiographs of the head
are rarely used now
PA
view
Lateral
Waters view head tipped
back to view maxillary
sinuses
Which would you rather
read?!?
This film shows round,
punched out osteolytic
lesions and is the classic
appearance of

Multiple Myeloma
Multiple myeloma is the most common
PRIMARY bone malignancy. What is the
most common bone malignancy overall?
 Q: Getting skull
films on these
patients was a
waste of time.
Why?

A: Because the effect of

trauma on the brain
needs to be evaluated.
A skull fracture will not
affect patient outcome.
A brain injury will.
 Head Imaging Modalities
CT
Modality of choice for evaluating sinusitis
Fluid in sinus cavity, mucosal thickening, sinus wall
erosion
BUT, imaging is only indicated for complicated
sinusitis
Modality of choice for evaluating facial and
skull fractures
Modality of choice for acute head and/or neck
trauma
Modality of choice for detecting acute
hemorrhage
3D rendered CT
images
 Head Imaging Modalities
MRI
Modality of choice for evaluating most other
spinal cord and intracranial abnormalities
Such as head and neck tumors, white matter
disease, multiple sclerosis, congenital brain
abnormalities, etc.
Has better tissue contrast than CT (so, for
example, its easier to distinguish a tumor from normal brain
tissue)
Okay, thats all for now!
 Sources
Herring W. Learning Radiology: Recognizing the Basics. 2nd ed. Philadelphia, PA:
Elsevier; 2012.
Johnson TR, Steinbach LS, ed. Essentials of Musculoskeletal Imaging. Rosemont,
IL: American Academy of Orthopedic Surgeons; 2004.
Erkonen W, Smith W. Radiology 101: The Basics and Fundamentals of Imaging. 3rd
ed. Philadelphia, PA: Lippincott, Williams, and Wilkins; 2010.
Mettler F. Essentials of Radiology (2nd ed.). Philadelphi, PA: Elsevier Saunders; 2005.
Ouellette H, Tetreault, P. Clinical Radiology Made Ridiculously Simple. Miami, FL:
Medmaster; 2007.
Novelline R. Squires Fundamentals of Radiology. 5th ed. Cambridge, MA: Harvard
University Press; 1997.
www.radiologyinfo.org
www.studentbmj.com
www.radiology.co.uk/srs-x
sfghed.ussf.edu
ercweb.bcm.tmc.edu
http://www.radiologyinfo.org/
www.vh.org
www.xray2000.co.uk
www.mds.qmw.ac.uk
www.netmedicine.com/xray/xr/htm
Radiology Review for the Non-Radiologist, American Medical Seminars DVD series
sprojects.mmi.mcgill.ca/icm_c/frameright.htm
Radiology Review for the Non-Radiologist Volume I & II DVD series from American
Medical Seminars