Tuesday, January 06, 1998: (Day 1)
Dr. Kettner Sick Today; No Class
Wednesday, January 07, 1998: (Day 2)
Dr. Kettner passed out syllabus and lectured
Skipped Class to Study for Comp Boards II.
Monday, January 12, 1998: (Day 3)
Dr. Kettner is a no show
Dr. Brahe reviewed cervical normal anatomy.
Review normal lateral cervical.
Pre-vertebral soft tissue
Articular pillar fracture is most common missed fracture of cervical spine, must take pillar view.
Fractures of the odontoid are also very common.
Type 1 is in the middle of the neck of the odontoid and is usually horizontal
Type 2 fracture goes through right at the top of the C2 body or the base of the odontoid. MOST
Type 3 goes through the C2 body.
Other common fracture of cervical spine is spinous process of C7 (clay shovelers). This is an evulsion
of the spinous process.
Para odontoid sulcus is a normal variant. Do not mistake it for a fracture.
Tuesday, January 13, 1998: (Day 4)
Dr. Kettner a no show:
Dr. Brahe lecuture over normal anatomy of cervical spine.
15 minutes late for class.
Circles in posterior part are lamina
Circles on the body are pedicles.
Flexion and extension views
Looking for ADI, Spinal laminar line, front of vertebral bodies, posterior vertebral body line.
If a vertebrae moves more than 2 mm from the one above or below it may be significant
Are spinouses coming together in extension and separating in flexion?
Look at disks (especially extension) to make sure there is no vacuum phenomenon. Air can get in the
disk with degeneration.
Is canal space large enough? Cannot really see stenosis unless you use MRI or CT.
Soft tissue space.
Oropharnyx and nosopharnyx come together to make pharynx proper.
Lymph node calcification would not be as opaque as bone and will be popcorn or irregular shaped. It
might be found over the spinous of C2.
Stylohyoid ligament is capable of calcifying.
Flexion view, the chin should approximate the chest.
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Wednesday, January 14, 1998: (Day 5)
Dr. Kettner is back!
RAO you see the Right IVF
LAO see Left IVF
IVF are at a 45o off of midline. They point at 45o and down at 15o declination.
Side against film gives you IVF and IVF point down at 15 o. These are the two facts we need to
LPO get Right IVF. With the posterior you get opposite oblique.
14x17, 40 inches, bucky
Top of film is 2” above C7
Central ray is to middle of the film
Collimation is brought to midline.
Thoracic exam is not to investigate pulmonary system.
Series includes A-P, lateral and P-A chest.
Use a long time setting with patient breathing out to blur out ribs.
Cannot get good visualization on upper thoracic spine in a lateral unless it is a very slim patient. This
is due to the large amount of muscle. Take a swimmers view to visualize cervical-thoracic junction
Routine: A-P and lateral (weight bearing)
In lateral lumbar scoliosis, place convexity against film and shoot into the concavity.
A-P lumbosacral spot
Lateral Lumbosacral spot
Right and Left posterior oblique (Supine on the table)
Degenerative anterolesthesis of L5 is seen more commonly in the female than the male. This is
because the force into the apophyseal joint is greater.
Midpoint of L3 should hit anterior 1/3 of the sacrum with a gravity line drawn.
Normal distribution is about 60:40 ratio. This reverses when you shift to posterior weight bearing.
This can change with a loss of the cervical lordosis. This compensation can give rise to repetitive wear
in the lumbar spine and lead to other problems.
Flattening of the lumbar curve is an effect of discogenic spondylosis.
Furthesst lumbar spine posture should change is a straight spine in full flexion. It should never reverse
Soft tissue of lumbar spine can see calcification of aortic-iliac transition. Expect to see posterior wall
and anterior wall of abdominal aorta. It should not exceed 3.8 cm. If it does, there may be a
questionable aneurysm. It is questionable because of the magnification of X-Ray may change
measurement. Another study should be done.
Escasia: refers to enlargement of vessel below limits of aneurysm but above the normal limits.
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Thursday, January 15, 1998: (Day 6)
Two hours of class today
Disk space at L5 is largest in the column. There must be a 50% reduction before it is considered
Convex side of scoliosis is placed against the buckey for imaging.
Stenosis ratio of 3:1 is considered normal in the lumbar spine. Ratio is Body:Spinal Canal (back of the
vertebral body to the spinal-laminar junction.
In the cervical spine the A-P diameter is measured by the A-P dimension of the canal and the ratio of
Body:Spinal Canal in normally 1:1
Ligamentum flavum buckles when disk space decreases. The article handed out in class discusses this
in detail. “Applied Diagnostic Imaging”. The Ligamentum Flavum thickens as it buckles or
something. Read the article.
Relationships existing between motion segments
IVD is a universal joint. As aging occurs and collagen complex changes, nucleus pulposus
desiccates and causes an abnormal shift of weight bearing. It moves posteriorly onto posterior
articulations, which are not made to support the weight. This can lead to spinal stenosis. The
beginning of the end of motor segment desiccation is the dehydration of the nucleus pulpousus.
As we fracture end plates the disks space begins to loose height. The disk does not shrink as was
thought in the past. In some cases the disks actually get bigger and the disk moves into the end
plates. Disk space is reducing, not the actual disk. As the disk space reduces, the vertical
dimension of the foramen gets smaller by the superior facet slides down along the inferior facet.
As the disk space reduction follows there will be narrowing of the neural foraminal reduction in
the vertical dimension
Stenosis in the A-P plane is already undergoing change.
The very first thing you should be in the habit of identifying on the lateral lumbar is the abdominal
aorta of 3.8 cm or less.
Cannot see facet tropism or asymmetry on the L5-S1 spot shot because we cannot see in the plane of
There is a poor clinical correlation between the angle of the facet, facet asymmetry and the
degeneration of the joint. (Current literature)
Neck of scotty dog is pars interarticularis. This is also a part of the IVF. On this projection, the IVF is
between the pedicles, (the head of the scotty dog superiorly and inferiorly.)
Know etiologies of misalignments of the lumbar spine. It is not due to muscles, it is due to the joint
spaces. (look this up in the article)
Stopped paying attention about second half of second hour of class.
Define instability in the flexion view is a break in the plane. All the lumbar end plates should be parallel.
The clinical correlation associated with instability is not well defined.
Loss of parallelismin flexion of 2mm is the upper limit of the movement of segments
Coronal plane is rotation and coupling.
Clinical correlation associated with instability is yet to be illustrated at a high accuracy.
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Tuesday, January 20, 1998: (Day 7)
One hour of class:
Discuss Herzog Article: “Mechanical and Physiological Responses to Spinal Manipulative Treatments”
Thursday, January 22, 1998: (Day 8)
Monday, January 26, 1998: (Day 9)
Begin chapter 7
We must have a scanning pattern so that we look at the entire radiograph.
Expactation should drive the search process
A. Soft tissue:
Range of density from most to least is the first thing to look for.
Bone/calcification: sports injury associated with muscle.
Calcium formation is common in repetitive injuries.
Edema: trauma, infection and neoplasm provoke edema.
Solid periosteum: thick and solid is associated with healing fracture. Callus is a term for solid
and thick. This means there is healing bone.
Layered or Laminated: aggressive periosteal response such as neoplasm or infection.
Codmans Triangle: invading process has elevated periosteum. Aggressive neoplasm and
infection. This means there is now invasion of the soft tissue.
Hair on end: most aggressive periosteal response.
Undulationg or waving prompted by ischemic tissues in assocition with bone. An example
would be a diabetic fibula. Insufficiency of the vasular.
We normally do not see the periosteum. It is microscopic layer along the cortex. Periosteum
reactions require additional testing to exclude a life threatening process.
Dense bone in contrast to medullary bone. Radioopaque
Compact bone in contrast to medulla, which is spongy.
Expect to be uniform in thickness and radiographic density
Thinning of the cortex defines osteoporosis.
Osteoporosis belongs to metabolic, nutrition and endocrine categories.
May be focally eroded: L4 focal cortical erosion might be AAA. May be eroded by infection,
neoplasm or vascular erosion.
Lysis or focal erosion often has an associated periosteal raction.
Cortical thickening (generalized) is associated with Paget’s. Osteopetrosis thickens cortex.
Lucent, spongy bone which houses hematopoeitic system, particularly in the Axillary
If medulla becomes opaque, suspect neoplasm or chronic infection. Infarction can also be
Blastic metastatic disease may change density. Chronic osteomyelitis may also change
lucency by increasing it.
Infection or neoplasm may make a lucent hole in a lucent medullary cavity.
Osteoporosis begins in spongy medullary bone and then engages cortex. Cortical bone is last
reisivior of osseous density.
Type I osteoporosis is medullary and is due to menopause
Type II is cotical loss and occurs in male and female. They are advanced stage patients.
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E. Joint thickness
Refers to reduction of cartilage
Osteoarthritis is classic
Once joint thickness gets thinner, alignment becomes affected.
F. Joint alignment
Degenerative processes of joints creates mal-aligned joints.
Alignment is predicated on joint thickness
Muscle spasm can change alignment.
This discussion is centered on degenerative joint diseases.
May be traumatically altered
G. Joint function:
Degenerative and traumatic mal-alignment will alter joint function.
The last three flow in sequence. Function will follow change in alignment which will follow
joint function and connective tissue will change their tonicity.
Tuesday, January 27, 1998: (Day 10)
Table 39-1 (Resnic’s Book)
Classification of Degenerative joint Disease:
A. Abnormal concentration of force on normal articulations
1. Intra-articular malalignment
epiphyseal dysplasias: genetic impact leading to change in epiphyseal margin.
neuromuscular imbalance: one joint surface repetitively displaced.
2. Extra-articular malalignment
inequality of leg length
congenital and acquired varus or valgus deformities
3. Loss of protective sensory feedback
Neuroarthropathy: seen in diabetes mellitus (longstanding) in the foot (tarsals and
metatarsals). Syphilis is also problem in spine, pelvis and knee. Associated With the 6D’s of
Charco’s neuropathic process. 1. Destruction; 2. Dislocation; 3. Distension (capsule); 4.
Debris; 5. Density; 6. Disorganization. Syrinx or syringomyelia is the third
entity causeing neuroarthropathy. It originates within the cervical spinal cord. Pathogenesis
is unclear but is associated with desention of cerebellar peduncles. Obex gets increased
pressure due to CSF diffustion and pumps CFS into the spinal cord at high frequency and
volumes. This causes constriction of the spinal cord in the canal. Target is in the
glenohumeral joint for the Neuropathic joint. Shunting is management for syrnix. Classic
sign is shawl distribution of sensory deficit.
intra-articular injection of steroids
occupational: must keep joint in motion. Vitamin E halted the progression of osteoarthritis of
the knee in a two year study.
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Thursday, January 29, 1998: (Day 11)
Loss of articular cartilage is associated with instability.
Anterolesthesis can to 20 or 30% with pars still in tact.
Degenerative changes into he disk:
Subchondral bone has areas of focal lucencies: called subchondral cyst.
Hypercellularity and hypervascularity will invite sclerosis
Joint pain associated with movement, limitation of motion, stiffness after periods of rest and referred
Signs of osteoarthrosis
Limitation of motion
Changes in shape of the joint
Spasm or atrophy os surrounding muscles
Fine crepitation on joint motion.
Osteoarthrosis is not arthritis: it is a degenerative disease. Osteoarthritis is an inflammatory disease
and the only true one is Rheumatoid Arthritis.
Term arthrosis never applied to disk.. Discogenic spondylosis or spondylosis deformans is the proper
terminology for degenerative change in the IVD
Arthrosis is the proper term for uncovertebral and apophyseal joint arthrosis.
Uncovertebral joint arthrosis may be complicated by osseous foraminal encroachment. The vertebral
body “ridges” and encroaches in the IVF. Creates an hour glass shape.
Get radiologic/pathologic handout from library:
Ebernation: Sclerosis you need hypercellularity and hypervascularity.
Mach line: look this up. Common place is tib/fib. It is result of two overlaping bones and can easily be
confused with a fracture. He doesn’t care if we know what it is called but he wants us to know what it is
Monday, February 02, 1998: (Day 12)
Continue going through the cervical spine.
Spondylosis at 5/6 cervical spine
Decreased joint space
Sclerosis extends beyond subchondral zone.
Comparison of intersegmentalmotion in symptomatic and asymptomatic subjects
Measure mobility of the column by using the PENNY ANANLYSIS. (Dvorak, Spine 13;748,
There were no significant difference in symptomatic and asymptomatic at C1, C2. There were
significant differences in symptomatic and asymptomatic patients in other areas of the spine.
ROM segmentally in the cervical spine:
Fell Asleep in Class, rest of notes are shitty
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Tuesday, February 03, 1998: (Day 13)
Went over article “Applied Diagnostic Imaging
Natural history of a herniation: course of an untreated diagnosis
Size of herniation has nothing to do with the clinical otcome of the patient. Objective is treating the
complications of the herniation, not reducing the size of the herniation.
Sol and Sol found some cervical spine herniations and watched their natural history. Cervical spine seems
to respond to non-operational methods better than they expected.
AHCPR Guidelines: agency of multidisciplinary origin which routinely set out guidelines for controlling
certain conditions. This is to prevent the over-utilization of surgery, elective. There were many times more
hysterectomies in spokane washington than other areas with less surgeons.
Thursday, February 05, 1998: (Day 14)
Not taking notes today. Don’t feel like it!!!
Monday, February 09, 1998: (Day 15)
Did not takes notes today, Dr. Atherton Lectured.
Tuesday, February 10, 1998: (Day 16)
Twelve significant signs of trauma:
Abnormal soft tissues:
a. widened retropharyngeal space
C2: 7-9 mm
Abscess can be space occupying mass. Generally pediatric problem.
b. Widened retrotrachea space
C6: up to 22 mm
Widened by the same differential as above
When a. or b. are present there will be displacement of letter c.
c. Displacement of prevertebral fat stripe
If a. or b. are present we will push fat stripe forward
Lucent line that is difficult to see.
If present and arched forward usually means hematoma
d. Tracheal deviation and laryngeal dislocation.
A-P projection with airway diplaced form midline
Usually indicates trauma and displacement is caused by hematoma
Goiterous thyroid, lymphoma or thyroid tumor could also cause this.
Abnormal vertebral alignment:
a. Loss of lordosis:
b. Acute kyphotic hyperangulation:
Very significant injury; preface to dislocation and joint is about to dislocate.
Reverse of cervical curve. There is a sharp angulation forward.
It is only one hyper-angulated segment
11o or more angulation is an unstable spine. It is an emergency.
Translation of 3.5 mm or more.
This requires that the flavum and capsule must be torn.
c. comes before b.
Grade 3 is Kyphotic hyperangulation
Grade 4, bilateral and unulateral dislocation
c. Widened interspinous space:
Must first tear nuchal ligament, then interspinous, then Flavum then capsular ligaments then PLL.
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Widening represents tearing of the nuchal and interspinous.
This must happen first before Acute Kyphotic Hyperangulation.
There should never be more 2mm between the spinous processes.
Grade 2. Interspinous ligament is torn and widens interspinous space. Manipulation is good here
if neck is stable
Grade 1 is entirely clinical. Pain on active range of motion strain or sprain.
Equivalent of scoliosis: curve in the thoracic spine is scoliosis, lateral flexion and rotation In the
cervical spine is torticollis.
e. Rotation of vertebral bodies:
Segmental rotation of spinal segment.
One spinal segment rotates, C4 rotates and C5 does not. How does this work? In order to do this
it must be a rotational injury so that rotary ligaments are violated.
If it is musculature, there will always be coupling. (movement of one above and below)
a. Abnormal middle atlantoaxial joints
Interval between the dens and the atlas (ADI)
3 mm in adult
5 mm in child
if there is a gap, it is probably RH. It is unusual in trauma
b. Abnormal intervertebral disk.
Abnormal if too wide. This is in context to injury.
If too narrow it is spondylosis
c. Widening of the apophyseal joints.
Wednesday, February 11, 1998: (Day 17)
Did not takes notes today
Thursday, February 12, 1998: (Day 18)
Monday, February 16, 1998:
No School, Presidents Day
Tuesday, February 17, 1998: (Day 19)
Wednesday, February 18, 1998: (Day 20)
Late to class, Didn’t take notes today.
Thursday, February 19, 1998: (Day 21)
No notes, Study GI/GU Exam II during class
Monday, February 23, 1998: (Day 22)
Green stick fracture is an incomplete fracture
Fracture repair is reiteration of bone growth itself
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Tuesday, February 24, 1998: (Day 23)
Osteoarthritis is at saddle joint , trapezium/metacarpal joint.
Intercarpal ligaments are also known as the intrinsic ligaments. They are very tough but they tear.
Extrinsic ligaments cross multiple sites and they criss-cross the wrist.
Injury in the wrist:
Mechanism of injury is a fall on the outstretched hand. Hyperextension or hyperflexion.
Scaphoid fracture, there is radial deviation of distal carpal row. Waist of Scaphoid is most common
The most common fracture of carpal bones is mid-waist scaphoid. Find pain, decreased ROM.
Percuss second digit distally, this will isolate the scaphoid fracture. It will vibrate into trapezoid and
this will go to scaphoid and trigger the pain.
Pain also occurs in anatomical snuff box. Percuss at bast of thumb over swelling and you are
percussing over the scaphoid.
If patient falls on an outright hand, use a 4 view radiographic series to rule out fracture, especially
when there is pain over the percussion sites.
If you blow this call, you take away function of the wrist.
Second injury in the wrist:
Lunate is other trouble spot
Lunate is dislocated and is the most commonly dislocated carpal bone.
The only symptom is pain, not much else clinically.
Hyperextension injury pulls apart the lunate to dislocate.
Repeat x-ray after 10 days if you do not see fracture. If patient is asympotmatic after a few days, cancel the
If there is chronic pain and radiograph is negative after 10 days go to a bone scan.
If you fail to diagnose a scaphoid fracture the proximal pole dies and now you have a dead bone and have
lost the use of the hand.
Second x-ray, fracture is more visible due to decalcification and osteopenia. The fracture has also moved
during the time between films and now you can see it.
Arcs (Gayulia) are a source of reference of geometic value.
First arc is unbroken line connecting first row
Second arc is distal aspect of procimal row
Third arc is proximal aspect of distal row.
Lateral view of wrist
Ulna must reside inside the radius or the radiograph will not show what we want it to.
Most important feature is that the radius lines up with the scaphoid and the capitate.
Wednesday, February 25, 1998: (Day 24)
Late to class, didn’t take notes today.
Thursday, February 26, 1998: (Day 25)
If there is a lucency in the posterior fat pad of the elbow it is 90% indicative of a fracture.
Little Leaguers Elbow: An evulsion fracture of the medial epicondyle epiphysis. Curve balls are
outlawed in little leagues because of this.
Throwing forces generate bone and that developes cortex bone it the medulla and the limb can also
grow in length during the formative years. Especially if the elbow is put through repetative motion.
Osteoarthritis will evnentually develop in the elbow with the longer bone.
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Osteoarthritis is unusual in shoulder joint and only show up in repeted trauma
AC Joint is subject to sprains.
Osteophytosis along margin of joint tells us of previous injury.
Arthrotide: Repetative trauma multiplied by 10 years.
Rotator cuff undergoes dystrophic calcification under repetative trauma.
Bankhart lesion: Epinym of shoulder means that bone has fractured or cartilage has been torn. Need
MRI to see the cartilage portion.
Hill Sachs deformity: Epinym. Open pack position of glenohumeral joint. Abduct and Externally
rotate arm. This this is the dislocation position. Hill Sacks Deformity is the notch made the the head
of the humerus from knocking on the labrum after repetitive dislocations.
Legg Calve Perthes: idiopathic form of avascular necrosis that happens in the epiphysis.
When patient has pain at rest it is very bad. Usually means ischemia.
Complicatin of injury may be a massive bone in th soft tissue immediately adjacent to the bone. This is
myositis ossificans. This is an old bleed that matured. Most dissapear in about a year. They do not
transform into malignant bone.
1. 3:1 Male predominence
2. Age range 4-15 years old
3. History of injuryt – 50%
Theories of etiology
1. Trans or subchondral fracture
Sites (may look like a sprain but symptoms persist. Re-radiograph in a week or 10 days)
Knee is most common
Most commonly injured joint in the body as far as sports injury is the ankle.
Talus should be parallel to tibial roof (Paffondl)
In order for gap to develop, anterior talofibular ligament must be torn. Usually also tear calcaneofibular
ligament along with it. These are torn on inversion.
Stress views reproduce the injury on radiographs.
There is mechanoreceptor injury along with ligamentous injury. This will eventually cause pain from
osteoarthritis due the joint never working well ever again. Brain does not communicate with joint as well
because of mechanoreceptor disruption.
Lewis Saulter Classification.
Monday, March 02, 1998: (Day 26)
Tuesday, March 03, 1998: (Day 27)
Didn’t feel like taking notes
Wednesday, March 04, 1998: (Day 28)
Thursday, March 05, 1998: (Day 29)
Didn’t feel like taking notes
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Tuesday, March 31, 1998:
Review for final:
Normal anatomy and know the densities.
Air is abnormal when it is not supposed to be there. Infection, subcutaneous emphysema air
tracking under skin and is often associated with COPD.
Soft tissue in the foot is likely to get infected due to diabetes. This shows air.
Trauma of the chest may also show air density due to laceration or compound fracture.
Clostridim perfringes are gas generators and frequently seen in soft tissue of foot particularly with
Trauma in chest that would give rise to subcutaneous air is pneumothorax. There is air where
there should be a vacuum and now you collapse the lung and have a pneumothorax.
“Lipomatosis” is iatrogenic or cushings drives fat all over the body.
Liposarcoma: this would be exception of fat being a benign entity. Liposarcoma is cancerous.
Pathological fracture is something that has replaced bone. Metastasis or myeloma.
Fatigue bone: increased stress on normal bone.
Insufficient bone: normal stress on abnormal bone
Osteoporsis is the cousin of strss fracture. It is a ratio of production vs reduction. Ratio is less
than 1 in ostoporosis.
Degenerative: DDx is osteoarthrits. Can be 1o and 2o. Charco’s arthropaty is underoing accelerated
degeneration. Etiologies are diabetic, syphilis, syrinx and alcoholism.
Diabetic location, syphilis is spine and knee, syrnx is shoulder and elbow. Alcholoic is same as
diabetes (tarsals and intertarsals). With charcos you have 6D’s.
Complications of osteoarthropy are profound because they are associated with stenosis, instability,
Complications may cripple you.
Infections: Complications may kill you.
Metabolic: Gout, Pseudogout, Amyloid,
DISH: can stenose due to the PLL.
Discogenic spondylosis and all the AKA’s
Know these well.
C/S important because of AA instability with increase in ADI (> 3mm or 5mm)
DDx includes RA and downs syndrome, reitters, AS. OS odentoidium
Instabliity in fractue patterns. Worst is flexion tear drop, 45% have quadropeligia.
Pillar fracture causes pain for rest of life but not immediately life threatening.
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