LANGUAGE OF RADIOLOGY
Dr. Joseph Thomas
Part IV Review Fall 2004

Black=gas, fat
Gray=muscle, water, soft tissue
White=bone, metal

Motive steps for taking a film

1. Identify view

2. What is motive for taking film?
	Oblique lumbar - view pars and facets
	Oblique cervical - view IVF
	PA ulnar deviation - scaphoid and lunate
	Cervical flexion/extension - for abnormal motion and/or fusion, stability or instability
		Contraindicated in all fractures (fx) except clay shoveler's fx
		Contraindicated in traumatic dislocation, infection, malignancy
Only time you see a dislocated facet on a flexion film is with inflammatory arthritis, usually RA

3. Color motive - How does film appear, 5 color motives
	1-Bone is white, soft tissue is gray, gas is dark or black
	a normal motive film = good quality film
	2-Bone is white, soft tissue is white
	Underpenetrated/underexposed = a. lousy bone film, b. or taken for soft tissue.  Always check bone first on underpenetrated film then check (check) soft tissue  (abdominal aorta primarily)
	3-Bone is dark, soft tissue is dark
	Overpenetrated/over exposed = a. lousy bone film, b. or taken to see one area of film
	don't worry about what you cannot see, only what you can on an overpenetrated film.

Rule:  if you can't see it, you can't read it, you can't diagnosis it

	4-Bone is gray, soft tissue is gray = osteopenic
	First look for condition to explain osteopenia   a. hyperparathyroidism, b. lytic mets, c. multiple myelona (MM), d. RA, e. anylosing sponylitis (AS)
	If you cannot find a condition to explain osteopenia then you change your diagnosis (dx) to osteoporosis.  To confirm osteoporosis is on a film you must see pencil thin cortices going all the way around vertebra.
	5-Bone is white, soft tissue is dark or black
	Bone film - problem is in the bone

4. First impression - either normal or abnormal.  Are you distracted by something on film?
Yes = first impression is abnormal, No = first impression is normal
If your first impression is abnormal then go to second impression, which is motive step 5.

5. Second impression.  Is it congenital, is it acquired, am I unsure.  If second impression is congenital
	Rule:  once you have a congenital anomaly you no longer worry about alterations of color from Pagets, infections, or malignancies.  You no longer worry
	about subtle fx or subtle dislocations.  The only time you will pick an acquired condition once you have a congenital anomaly on the film is if the acquired
	condition is OBVIOUS ENOUGH to override the congenital anomaly.

6. Then check normal anatomy for age, sex and deformity 
a.  Age - biggest differential in radiology,  b. Sex - important in pelvis only,  c. Deformity    -defined as the bending or twisting of bones with the cortex still relative intact.  Deformity in spine - Pagets or congenital (cong) anomoly.  Deformity in the extremities - Pagets or fibrous dysplasia.

ilia and sacrum are considered part of the extremities for radiological/bone pathology.

MOTIVE IS MY FRIEND.  MOTIVE WILL GET ME A LICENSE.

LATERAL CERVICAL SPINE FILM - Motive - Routine Scout, 15 steps

1. Check ADI space
2. Spino-laminar line of C1 in relation to C2
3. Come down front of vertebral bodies
4. Check base of dens
5. Approximate dens for height, alignment and color
6. Check vertebral bodies for alteration of shape and alteration of color
7. Check disc spaces for alteration of size, alteration of color
8. Check posterior arch of atlas
9. Check space between occiput-C1, C1-C2
10. Check pedicle of C2
11. Come down back of vertebral bodies
12. Check facets
13. Check spino-laminar lines
14. Check spinouses
15. Check soft tissue in from of spine

Step 1. ADI space.  Normal ADI should be no more than 3 mm in adult and 5 mm in child.  Normal ADI space appears as a thin black line.  If width of ADI space is  SIMILAR to the width of the anterior tubercle then you have an increased ADI space.
if ADI space exists rule out agenesis of dens.  then determine if it is normal or abnormal in width:  abnormal = increased ADI due to most commonly due to Downs (not xray dx), trauma, RA, AS, PA (psoriatic arthritis), Rheiters syndrome.  except Downs, these conditions all have inflammation in common.
Downs, 20-30% have absence of transverse ligament of atlas.   Transverse ligament serves to maintain relationship between dens and anterior arch of atlas.
5 signs of inflammation:  swelling, heat, loss of function, pain, inflammation = loss of function due to laxity.

Step 2. Check spino-laminar line of C1-C2 to see is atlas is in place or displaces. 
If atlas is anterior there are 4 possible reasons. 1-increased ADI, 2-fx dens, 3-unstable os odontoidium, 4-agenesis of dens.
If atlas is posterior there are 3 possible reasons: 1-fx dens, 2-unstable os odontoidium,
3-agensis of dens.
To check to see if atlas is in place draw straight verticle line along the back of C2 body and roll line posterior until you hit the mid-point of the spino-laminarline of C2.  It should hit some portion of spino-laminar line of C1 for atlas to be in place.

Step 3. Come down front of vertebral bodies. Check for 4 things.
	1-lipping and spurring of DJD and infection.  don't rule out until you check disc spaces
2- hyperostosis aka candle-wax deformity aka anterior spinal bridging of 4 or more segments to indicate DISH.  DISH - calcification of the anterior longitudinal ligment.  Disc spaces are USUALLY (USU) preserved.  DISH  NEVER involves the facet in terms of fusion.  It is non-inflammatory.  There is a 30% correlation between DISH and diabetes mellitus.
3-syndesmophytes = inlammation spurs.  Calcification of the ALL and annular fibers of disc.  Bodies’ response to inflammation is fusion.
2 types of syndesmophytes  
1.  Marginal go with AS .  To determine if it is a marginal syndesmophyte of AS you go to the anterior aspect of disc space.  Does calcification disappear when you cover it up?  Yes = marginal, No = something else.  Another way to confirm marginal syndesmophytes of AS is to look for eggshell calcification going around disc.  This is not always present.

2. Non-marginal go with PA (psoriatic arthritis) and Reiter’s syndrome.   Only time you think of PA or Reiter’s syndrome in spine is if you come down
from of bodies and see what appears to be hyperostosis aka candle-wax drippings of DISH BUT facets are fused.  Then think PA or Reiter’s.
		Differentiate with history (hx).
	4-Avulsion fx or compression fx.  
a. Avulsion fx- primarily teardrop fx = avulsion of anterior inferior aspect of vertebral body and bony fragment appears like a tear rolling down. most commonly at C2.  Mechanism of injury usually hyperextension.   
b. Compression fx = loss of anterior bdoy height of 25% or more  - MOPIT = malignancy, osteoporosis, Pagets, infection, trauma.
	Malignancy is an all-encompassing term for lytic mets and multiple myeloma (MM) 

Step 4. Check base of dens for radiolucent (lucent) line.  if you see it, 4 possible reasons. 
1-fx dens, 2-os odontoidium, 3-agensis of dens, 4-Mach line (shadow).
Locate base of dens by locating sclerosis (TP of C2) and go to the top of it.

Step 5.  Approximate dens for height, alignment and color.  

1-Height - Roughly equal to height of C2 body.  Majority should be below occiput to rule out basilar invagination.  Basilar invagination may be due to Pagets, fibrous dysplasia or trauma.
2 lines to measure for basilar invagination: Chamberlains and McGregor’s.  Chamberlains - Back of hard palate to posterior foramen magnum.  Dens should be nor more than 7mm above that line.   McGregor’s - back of hard palate to base of occiput.  Dens should be no more than 8 mm in male, 10 mm in female above line.

2-Alignment - look at front and back of body of C2 checking to see if dens is in place or displaced.   if displaced, likely one of two conditions - Fx dens or unstable os odontoidium.

Rule:  os odontoidium aka non-union of dens aka ununited dens usually. are not diagnosed off lateral cervical spine film. 

For boards there will be only 2 likely scenarios where you will be expected to dx os odontoidium off lateral cervical view: 1- you see a tomogram (looks like a blurry film) with radiographic signs of os odontoidium which are a lucency that is smooth with cortical margins around 2 fragments.  2- if you see the OBVIOUS radiographic signs of an os odontoidium - A BIG THICK RADIOLUCENCY that is smooth with cortical margins around 2 fragments.

Rule: anytime you have a bone displaced from itself assume fx until proven otherwise.  2 ways to prove otherwise, 1- office motive, 2- if you see the OBVIOUS radiographic signs of a non-union.

3- Color - Compare color of where the dens is to anterior inferior aspect of C2.  If it is whiter you can rule out agenesis of dens.
Rule:  anything that is penetrated on x-ray will appear darker/blacker.  Anything that is not penetrated will appear whiter.  More bone=less penetration=whiter.

Step 6. Check vertebral bodies for alteration of shape and color  
Alteration of shape = PFC, Pagets, fx, cong. anomaly.  
Alteration of color - vertebra is whiter = blastic mets, Pagets.  Blastic mets: seen in over age 40. Paget’s usually seen over age 50

Hodgkin’s (lesion usually lytic).  If you see ivory white vertebra in under age 30 think Hodgkin’s.
Most common cause of ivory white vertebra is blastic mets.

Rule:   once you have a white density in a bone, other than the proximal femoral heads or carpal bones, assume it to be blastic mets until proven otherwise.  5 ways to prove otherwise.  1-hx. Age, 2-labs, if alk phos is normal it's not blastic mets., 
3-bone scan -blastic mets is hot, 4-biopsy, 5-cortical thickening/enlargement or deformity of bone, dx-Paget’s.

Paget’s disease. 1-By the time a vertebra is ivory white due to Paget’s it will be OBVIOUSLY larger.  2-earliest x-ray sign of Paget’s is picture-frame vertebra appearance.  Picture-frame is due to cortical thickening 3-when checking for enlargement due to Paget’s check for vertical and horizontal enlargement.  The cause of enlargement is cortical thickening.

2 parts to bone: Cortex and medulla.  Medulla is highly vascular.

Blastic mets does not cause cortical thickening because cancer needs blood and blood is mostly in the medulla.

Vertebra is darker=lytic mets, MM.

Must first ask if color change is technical or pathological.  Technical color change means bones change one-way and the soft tissue follows.  Pathological color change means bones change one-way and soft tissue does not follow.

Step 7.  Check disc spaces for alteration of size and color.  DJD vs. Infection.  DJD classic signs are decreased joint space, subchondral sclerosis (aka ebernation) and if severe enough, lipping and spurring.  it affecting the bodies and discs = discogenic sponylosis.  Process - cartilage dies, decrease disc space due to bone rubbing, calcification in the form of subchondral sclerosis then lipping and spurring.  Atypical presentation of DJD  most commonly in lumbar spine.

5 secret questions of radiology - CLASS 
1-what is the Color
2-what is Location
3-what is Age 
4-what is Shape
5-what is Sex

Vacuum phenomenon - most commonly from DJD or trauma 

Infection - classic signs are 1-dec joint space. 2-joint space may turn whiter. 
3-Destruction of bone on both sides of joint.  Infection is only condition that gets into a joint space and destroys bone on both side of joint.  Joints have no blood supply so white blood cells can't get to infection.

Step 8. Check posterior arch of atlas.  Is it absent or present?
Absent - 1-can be cut away due to surgery. 2-eaten away due to malignancy.  
3-congenitally absent.

Look first for malignancy.  Check for teeth mark.  Smooth is either surgical or congenital.  To differentiate surgery from congenital absence, look for signs of surgery - staples or wires.  Congenital absence - can be agenesis of posterior arch and post tubercle or agenesis of post arch with post tubercle preserved.  Before you choose agenesis of post arch as diagnosis check to see if post arch of atlas is fused to occiput in occipitalization.  if it's present (post arch of atlas) then check for vertical lucencies of fx vs. non-union.  

Radiographic signs of fx: 1-jagged lucency, 2-usually no cortical margins around 2 fragments  3-there will be displacement.
Radiographic signs of non-union:  1-lucency is usually smooth, 2-usually will have cortical margins around 2 fragments,  3-no displacement.  Differential diagnosis for non-union is always fx and differential diagnosis for fx is always non-union.

Step 9. Check space between occiput-C1 and C1-C2 should be relatively similar.  If grossly unequal = problem.

Step 10.  Check pedicle of C2 for vertebral lucency = C2 fx = Hangman’s fx.  Due to hyperextension.  For part IV, Hangman’s fx classified as type IV spondylolesthesis

Non-union only occurs in areas of growth centers.  3 primary and 5 secondary calcification centers.
Primary 1-vertebral bodies, 2-one in each lamina  
Secondary 1-one in each endplate, 2-one in each TP  3-one in spinous.

Step 11.  Come down back of vertebral bodies cking: a. overall curve b. decrease in post body height, post body destruction to indicate malignancy. Malignancy is only diagnosis if there are no other signs of infection or trauma on film, c. subluxation vs. dislocation.  Subluxation is up to 10% slippage of facets still in line, anterolesthesis or retrolethesis.
To diagnosis subluxation use George’s line - drawn along back of vertebral bodies, start at bottom and come up.  Looking for break.  Name one above in reference to one below.  Use original line all the way to C2.

Dislocation = 25% or more slippage of one vertebral upon another with facets overriding or perching.  Name one above on one below.  Dislocation is of facets = fanning of spinouses.  Tears 4 ligaments 1-supraspinous, 2-infraspinous, 
3-ligamentum flavum, 4-capsular ligament.

10-25% slippage.  Check for fanning of spinouses.  Fanning = dislocation, no fanning = subluxation.

MOPIT-malignancy - decreased anterior and posterior body height.  But malignancy is only a diagnosis if no other signs of infection or trauma are on film.  
Osteoporosis - decreased anterior body height but posterior usually preserved.  (Usually affects 3 or more vertebral, initially) 
Paget’s - cortical thickening, enlargement or deformity of bone
Infection - destruction of bone on both sides of joint
Trauma - signs of trauma.  V-shaped defect or bony fragment/debris.

Compression fx due to trauma = compression fx
Compression fx due to any other cause other than trauma = pathological compression fx

Step 12. Check facets.   1-dislocation.  2-destroyed   3-fused.
Dislocated -RA vs trauma
Destroyed -RA vs OA
Fused- RA vs AS

Dislocation  - RA from trauma.  Look for signs of trauma on film.  V-shaped bony debris.  No signs of trauma = RA.
Destroyed - RA vs. OA.  Teeth marks in facets joints = rat bite erosions of RA.  Decreased joint space, subchondral sclerosis, if severe enough lipping and spurring = 
DJD = DJD of facets = facet arthrosis.

Fusion - RA vs AS.  Differentiation is down front of bodies.  Marginal syndesmophytes =AS. Without marginal syndesmophytes = RA.  
RA affects synovial joints.  Disc spaces are fibrocartlagenous joints.

Step 13.  Check spinolaminar lines.  Missing = spinabifida occulta.  in cervical spine, most common at C1, C6, C7.     spinabifida occulta of C1 = spondyloschises.
Cause is decrease in folic acid in first trimester of pregnancy.

Step 14.  Check spinouses.  Absent or present.
Absent.   1- surgical, 2-malignancy, 3- congenital absence
Surgical removal of spinous = laminectomy, a decompressive surgery.
Congenital absence of 1 or 2 SP, keep it as congenital.  Congenital absence of 3 or more, choose answer as surgical.  If present check for fx, in cervical spine fx most common at C6, C7, T1.  SP fx in cervical spine (including T1) = clay shoveler’s fx.  Mechanism of injury is hyperflexion.  50% of time when you have posterior pontical on film (for exam) you will also have a clay shovelers fx on film.  Post pontical aka pons posticus aka ponticular posticus.  Forms an arcuate foramen - transmits vertebral artery and suboccipital nerve.  Is there calcification of posterior atlanto-occipital ligament?

Child = under 13 years of age

Step 15.  Check soft tissue in front of spine.  3 INTERSPACES:  1-retropharyngeal (C4), no more than 7 mm.   2- retrolaryngeal (C5), no more than 14 mm.  3- retrotrachial (C6) no more than 22 mm in adult, 14 mm in child.   

Soft tissue swelling due to 1- trauma, 2- infection, 3- malignancy.

Rule:  if width of soft tissue is wider than the width of the vertebral bodies = soft tissue swelling is present.

In order to diagnose infection on lateral cervical film and soft tissue can be visualized, you must see soft tissue swelling.

If you see an IVF on lateral cervical film you have either 1-fusion of facets, 2-excessive rotation of facet, 3-neurofibroma.

Congenital or acquired fusion of 2 vertebra 
 1-look to anterior vertebral bodies, wasp-waist deformity = congenital,  
 2-anterior aspects of disc - draw vertical line, look for bulging.  If bulging exists =
acquired.  No bulging = congenital
 3-facets - how many SPs, how may spinolaminar line - 2 SP, 2 spinolaminar lines = acquired.  One SP, one spinolaminar line = congenital

Horizontal radiolucency going through a vertebral are usually not a fx  = mach line.
Fx vertebra - vertical lucency going through vertebra.

???hemospherical spondylosic vertebra is associate with discogenic spondylosis more specifically associated with uncinate arthrosis???

CERVICAL FLEXION/EXTENSION FILM
Will be read exactly the same way as a lateral cervical film.  Only difference is office motive. 
Motive=1- main ligaments you are interested in are transverse ligament of atlas and posterior restraining ligaments.
2- best view to diagnose occipitalization is cervical flexion.
3- ADI space shouldn't change from lateral to flexion to extension.   if it changes  = instability.

                                                        ---------------------------------------------------------------------------------------------------------------(End of day one)

Klippel Feil syndrome - multiple congenital blocks.
AS first affects SI joints, next thoracolumbar spine and moves up and down spine from there.
DISH - segments do not need to be continuous

Rule:  only two conditions that eat bone 1-malignancy, 2-infection.  To differentiate look to nearest joint. If destruction is on both sides of joint with alteration of disc space height = infection.  Destruction on one side of joint = malignancy. 

APOM – Motive=To view dens and anterior arch of atlas.
Step 1.  Is the den present?

Step 2. Check structures creating mach lines.  
1-Check for arches of atlas, smile = posterior arch, frown = anterior arch.   2-occiput 3- teeth.  Vertical lucencies going through tip of dens is not a fx.  It’s a mach line caused by the gap between the incisors.  To be a fx of dens you must see horizontal line.

Step 3. Check base of dens for lucent lines.  if you see it 1-is it thin or thick,  thin = dens fx,   
thick = os odontoidium.

Step 4. Outline dens to determine in place or displaced.  Displaced look at tilting or leaning odontoid indicative of dens fs.
3 types of dens fx 
	Type 1- Thin lucent line above the base of the dens.  a stable fx.
	Type 2 - Thin lucent line through base of dens.  Most common, most unstable
	Type 3 - Thin lucent line below the base of 'dens which goes upward.  A stable fx.

Step 5. Check paraodontoid interspaces for unequal or enlargement - suspect possible Jefferson’s burst fx.

Step 6. Check lateral masses of C1 with respect to body of C2 for overhang.  To check for overhang, go to the lateral aspect of C2 - draw straight vertical line upwards. 
Once overhang is present on one side could be 3 scenarios.
1-Overhang on one side but lateral mass on opposite side shifted in an equal amount = atlas laterally.
2-Overhang on one side but lateral mass on opposite side does not shift equally = Jefferson’s fx.
3-Overhang bilaterally = Jefferson’s burst fx.

Step 7. Check lateral masses for alteration of shape and color.
Alteration of shape:  PFC - Pagets, fx, and congenital anomaly
Alteration of color.  Whiter = blastic mets or Pagets, Blacker = lytic mets or MM

Step 8. TPs of atlas for alteration of shape - Congenital anomaly is primary condition.  
2 Most Common are: 
1-epitransverse process - Goes from superior aspect of TPs up toward the occiput, will see psuedoarticulation with occiput. 
2-paracondylar/paramastoid process - goes from occiput down towards superior aspect of TP and see psuedoarticular at superior TP.

Step 9. Check vertebral bodies of C2-C3 for alteration of shape and color.   
Alteration of shape PFC - Pagets, fx, congenital anomaly
Alteration of color - Whiter = blastic met or Pagets
		      Darker = lytic mets or MM

Rule:  NEVER put down blastic mets, Pagets, lytic mets, MM as diagnosis on APOM.

Step 10. Check disc spaces between C2-3 for alteration of size or color - DJD vs. Infection

Step 11. Check arches of atlas, SP of C2, SP of C3 for lucencies or spinabifida.  Sp of C2-C3 for horizontal lucencies of spinous fx (clay shoveler’s Fx)
spinabifida of C1 = spondyloschesis.

Step 12. Check soft tissue in and around the jaw.   Mostly affected by lymph node calcification.

Os terminale is a congential anomoly.  A thick lucency above the base of the dens.  To differentiate os terminale from a normal growth center, if tip of odontoid is in a diamond shape = normal growth center.  Any other shape is os terminale.

C2 body fx - with burst fx you see vertical lucency through base with break in cortex at both ends leading to OBVIOUS displacement of 2 pieces.

APLC –Motive=Routine scout film.  15 degrees cephalic tube tilt.
Mach line at C4 - laryngeal narrowing is normal.  NEVER put spinobifida of C4.

Step 1. Find last set of cephalic pointing TPs and assume it to be T1

Step 2. Check C7 TPs for  
1-Cervical ribs = a rib ARTICULATING with C7 TP, even if articulation is away from spine.  Classic history would be a secretarial worker, female, 35 year old, with neck pain and stiffness and paresthesia referring into right medial forearm and right medial hand.  This leading to thoracic outlet syndrome aka neurovascular compression usually seen in C8-T1 dermatome area.
2-Elongated, hypertropic TPs of C7.  Draw a line along lateral aspect of T1 TP and draw vertical line up, checking to see if C7 TP crosses that line.
Yes = elongated hypertropic TP of C7.
3-Check for TP fx.  Jagged lucency usually no cortical margins around 2 segments.  WILL see displacement.

Step 3. Check vertebral bodies for alteration of shape and color.
Alteration of shape = PFC
Alteration of color.  Whiter = Pagets or blastic mets
		     Blacker = lytic mets or MM
Compare to adjacent disc spaces to determine if it is pathological or technical

Step 4. Check disc spaces and uncinates for alteration of size and color.
Check disc spaces primarily for 2 condition DJD or infection.
Check uncinates for arthrosis = uncinate hypertrophy.  Normal uncinates appear verticle - batmans helmut ears.   Abnormal uncinates are flattened and going lateral = blunting of the uncinates indicative of uncinate arthrosis aka uncinate hypertrophy.

Most common cause of IVF encroachment is uncinate arthrosis = uncinate hypertrophy.  On Part IV uncinate hypertrophy often looking for IVF encroachment.

Step 5. Check SP for verteral lucency of spinabifida.  Most commonly seen on C1, C6, and C7.   NOT C4.   Check for horizontal lucency of SP fx.  Double spinous sign - vertebra appears to have 2 SPs most likely you are looking at double spinous sign indicative of SP fx.  Clay shoveler’s fx most commonly at C6, C7, T1.

Step 6. Check tracheal air shadow for deviation.  NEVER make a lung pathology diagnosis on any other film other than a chest film.

Step 7. Check soft tissue bilaterally for lymph node calcification vs. carotid artery calcification.
To differentiate: 1-calcific shape of V = carotid arterial calcification (bifurcation point)
2- single round white density it is either lymph node calcification or carotid artery calcification.  To differentiate you must see 2 or more round white densities.  Are they in a straight vertical line?  If yes = carotid artery calcification, no =lymph node.

OBLIQUE CERVICAL FILM –Motive=To view IVF, 15 degrees cephalic tilt.
NEVER choose occipitalization as diagnosis of cervical oblique film.
COP - cervical opposite the posteriors
Right post oblique views left IVF.
Anterior oblique marker is behind the spine.  See ipsilateral IVF, same side.
Posterior oblique marker is in front of spine.  See contralateral IVF, opposite side.

First IVF seen is C2-3.  C3 nerve root affected.  First number in cervical spine = disc space, second the nerve root.
IVF anatomy - anterior border is bodies and uncinates, superior and inferior borders are pedicles, posterior border is the facets.

Step 1. Start at top and come down.  Compare size and shape of IVF to the other.  Hole getting smaller, suspect IVF encroachment.  To confirm IVF encroachment must see hourglass IVF.  To confirm hourglass IVF must see middle pinching.  Hole getting larger - obvious on x-ray.  1-could be lytic mets of pedicle, this is rare.   2- agenesis of pedicle, 3-neurofibroma.   Lytic mets of a pedicle is rare.  To differentiate agenesis from neurofibroma draw straight verticle line along back of vertebral bodies and ask, do I see scalloping-out of the back of the vertebral bodies.  Yes = neurofibroma.    No = agenesis.   
Neurofibroma is a tumor of a nerve root.  They are expansile.  Dumbbell shaped IVF is radiographic sign referred to on Part IV.  Won’t actually see it.  Surgical intervention.  More than one neurofibroma = neurofibromatosis = VonRecklinghausens disease.  Can get cafe-au-late spots on thorax with smooth border, coast of California. 
Cafe-au-late spots also seen with fibrous dysplasia.  These spots have jagged border, coast of Maine appearance.

AP THORACIC FILM-Motive=Routine Scout.
AP thoracic film will be read exactly as AP lumbar spine in terms of square blockhead vertebra system.

Any condition that increases blood supply to bone will turn bone darker.  Any condition that decreases blood supply to bone will turn bone white.  Inflammatory conditions lead to an increase in blood supply to bone leads to a darker bone, you get absorption of bone.  Cutting blood supply to bone= bone death.  New bone laid down causing whiter appearance.  Avascular necrosis is whiter on x-ray.

LATERAL THORACIC FILM-Motive= Routine Scout
Step 1. Come down front of vertebral bodies looking for 4 things  
1-Lipping and spurring of DJD or infection but do not rule in or out until you check disc spaces.
2-Hyperostosis aka candle-wax dripping aka anterior spinal bridging of 4 or more segments to indicate DISH
	3-Check for marginal syndesmophytes of AS
	4-Avulsion or compression of fx

Step 2. Check vertebral bodies for alteration of shape or color.  
Alteration of shape – PFC: Alteration of color – Whiter= blastic mets or Pagets.  
Blacker= MM or lytic mets.

Step 3. Check disc spaces for alteration of size and color.  DJD or infection

Step 4. Check back of vertebral bodies.  1-overall curve, 2-decrease in posterior body height, posterior body destruction to indicate malignancy.  Malignancy is only the diagnosis if no other sign of infection or trauma on that.  MM when checking posterior body height always compare to 2 or 3 segments below.  MM affects many segments in a row.

Checking down from of thoracic vertebral bodies - MOPIT - for significant loss of body height.  Slight loss= 15%, significant loss =25%.  Slight loss of anterior vertebral bodies, up to 15%. Think 3 conditions:  
	1-mild compression fx
	2-infection
	3-Scheurman’s disease.
Mild compression fractures do not cause multiple endplate irregularities.   With infection destruction of joint spaces will be GROSSLY unequal.   With Scheurman’s disease destruction of joints will be relatively equal. 

Scheurman’s disease can also be seen on lumbar spine.  Radiographic signs of Scheurman’s disease are   1-slight loss of anterior vertebral body height or one or more vertebrae, 2-multiple endplate irregularities of 3 or 4 continuous vertebrae, 3-destruction from joint space to joint space will be relative equal, 4-if severe enough, you get increase kyphosis.     Seen between the ages of 10-15.  An avascular necrosis of secondary growth centers, specifically the endplates.

Avascular necrosis (AVN): All AVN in body id due to trauma can be repetitive micro trauma.  Best imaging modality for AVN is MRI, second best is bone scan.  Takes 2 months to show up on x-ray.

Schmorl’s node vs. nuclear impression.   Schmorl’s node is acquired.  Usu occurs on anterior 1/2 of vertebra.  Can occur superior or inferior aspect of vertebral.  Border is usually jagged.  Cause if trauma.   Nuclear impression aka persistent notocord.  Congenital.  Usually on post 1/2 of vertebra.  Border is smooth.  Will be seen as cupids-bow deformity on AP film.   If you see 1 or 2 Schmorl’s nodes, keep diagnosis as Schmorl’s node.  If you see 3 or more change diagnosis to Scheurman’s disease.  Have to be in same region of body, lumbar spine or thoracic spine.  Scheurman’s disease in lumbar spine appears as a giant Schmorl’s nodes.

Hyperparathyroidism vs. osteopetrosis.  With hyperparathyroidism you get sclerosis inferior and superior all the way to the front of bond - rugby jersey spine.  With osteopetrosis you get sclerosis inferior and superior, short of all the way to front of bone (on AP).  Aka marble bone disease, bone within bone appearance, sandwich vertebra.

LATERAL LUMBAR SPINE-Motive=Routine Scout.  8 steps
Step 1. Go down front of vertebral bodies looking for 
1-lipping and spurring of DJD or infection
2-hyperostosis aka candle wax drippings of DISH aka anterior spinal bridging 
3- marginal syndesmophytes of AS, 4-avulsion or compression fx.

Step 2. Check vertebral bodies for alteration of shape or color.  Alteration of shape - PFC. Alteration of color - Whiter = blastic mets or Pagets, Blacker = lytic mets or MM.

Step 3. Check disc spaces for alteration of size and color.  DJD vs. infection.

Step 4. Back of vertebral bodies 1-overall curve, 2-decreased posterior body, and posterior body destruction to indicate malignancy.   Malignancy is only your diagnosis if no signs of infection or trauma, 3-slippage of subluxation or spondylosis

Step 5. Check pedicles.  With pedicle fx you see a vertical lucency through pedicle.  Pedicle fx is very unstable.  Will have displacement.

Step 6. Check pars for pars fx.  Pars fx without anterior slippage = spondylolysis.   Locate pars, base of pedicle meets facets, 45 degrees.

Step 7. Check SP.  On lateral lumbar film they are usually over penetrated.  Absent   1-surgical removal, 2-eaten away due to malignancy, 3- congenitally absent. If you see missing SP and there are myelographic remnants most likely surgical removal.

Step 8. Soft tissue in front of spine.  Primarily looking at the abdominal aorta.  Usually L2-4.  Abdominal aorta should be no more than 3.8 cm.  Greater than 3.8 cm = aneurysm.  Greater than 5cm is a surgical referral.  Normal width of abdominal aorta is 1/2 to 3/4 the width of lumbar vertebral body.  If wider = aneurysm.  Part IV - 2signs for abdominal aorta are half-moon shape and curvy linear calcification

4 AKA for flat vertebra.  1- vertebra plana, 2-pancake vertebra, 3-coin-on-edge vertebra sign, 4-wrinkled vertebral sign.

Limbus Bone Vs Avulsion Fx.
Limbus bone is a non-union.  1-lucency is usually smooth, 2-usually will see cortical margins around 2 fragments, 3-no displacement.
Avulsion fx.  1-lucency is usually jagged, 2-usually no cortical margins around 2 fragments, 3-WILL BE DISPLACEMENT.
Bony fragment at front of vertebral body first assume it's a limbus bone.  To change diagnosis from limbus bone to avulsion fx you must see displacement.  To check for displacement, draw straight line along front of vertebral bodies.  If it falls in line, no displacement.  If it crosses line, displacement.

For every segment affected by AS marginal syndesmophytes must be bilateral and symmetrical.

Spondylo - 5 basic types 
Type 1. Dysplastic.  Usually congenital anomaly on film leading to anterior slippage.
	Type 2. Ischemic.  Spondylolytic.  Usually pars fx leading to anterior slippage.
Type 3. Degenerative.  Nonspondylolytic.  Usually DJD of facets leading to anterior slippage.
	Type 4. Traumatic. Usually pedicle fx leading to anterior slippage
Type 5. Pathological usually pathology in vertebral bodies such as lytic mets, MM, Paget’s leading to compression of vertebra with anterior slippage

For Part IV primary concern is type 2-spondylolytic spondylolesthesis.  Ischemic.  And type 3 -nonspondylolytic spondylolesthesis. degenerative.

On AP film spondylo appears as inverted Napoleon hat sign aka bowling of Brailsford aka Gendarme sign.  if seen on AP film you have at least Grade 3.
For Part IV NEVER should see lamina on AP lumbar film.

Meyerdings Grading System- made of two lines.  Ulman’s line and Ferguson’s line.
Ferguson’s (good only at L5-S1).  Measure back of body that slipped in relation to vertebra below.  5 Grades 1-5:
Grade 1 - 1-25%
Grade 2 - 26-50%
Grade 3 - 51-75%
Grade 4 - 76-100%
Grade 5 - 100%.
-If L5 very has slipped greater than 100% and dropped in front of sacrum = spondyloptosis
-If on border of two grades, go with lower grade.  Spurring on anterior aspect of sacrum only seen with spondyloslesthesis = buttressing phenomenon.

                                        --------------------------------------------------------------------------------------------------------------------------------(End day 2)

LUMBAR OBLIQUE-Motive= To view pars and facets. 
LOA - lumbar opposite anterior
Anterior oblique marker is behind spine
Posterior oblique marker is in front of spine.
In lumbar anterior oblique film you see opposite pars and facets.
With lumbar posterior oblique you see same side pars and facets

Anatomy of Scotty Dog - Nose is ipsilateral TP, eye is ipsilateral pedicle, ear is ipsilateral superior articular facet, neck is ipsilateral pars.  
Collar sign = pars fx.  Front leg is ipsilateral articular facet. Body is ipsilateral lamina.  Back leg is contralateral inferior articular facet, Tail is contralateral TP.
1- Pars fx is primary concern.  Can only diagnose as spondylosis.
2- Facets - Checking for facet inbrication.  Using McNabb’s line which is drawn along inferior aspect of the vertebral body, the superior articular facet of the vertebral body below 
Should not cross McNabb’s line.  If it does = positive McNabb’s line = facet imbrication.  True inferior aspect of vertebral body is higher line.  For superior endplate go to lower line.

SQUARE BLOCKHEAD SYSTEM
Step 1. Square blockhead = body.  
If you see vertical striations in a single vertebra is most likely hemangioma.  
Can have hemivertibra = butterfly vertebra.
Can have: Whiter - blastic mets or Paget’s, Darker - lytic mets or MM.  
Crushed blockhead - think malignancy.  Malignancy is only a diagnosis if no other signs of infection or trauma.  Vertebral body should NEVER be the same height as pedicles.

Step 2. Check 2 eyes.  If pedicle is missing it could be  
1-Lytic mets,   
2-Agenesis of pedicle.  Referred to as owl winking sign.   
To differentiate between lytic mets and agenesis, once you see missing pedicle assume it's due to lytic mets.  To change diagnosis to agenesis you must go to opposite pedicle.  Is opposite pedicle more sclerotic than the one above AND the one below.   If yes = agenesis.  If no = lytic mets. 
  
MM leads to a decrease of body height with SPARED PEDICLES = MM pedicle sign.  MM is referred to as a plasma cell leukemia, which is found in bone marrow.
Most bone marrow found in medulla of vertebral bone.  Appears cold on bone scan. 
Labs for MM - IGG-M spike on electrophoresis, reversed AG ratio, Bence-Jones proteinuria seen on urinalysis, normocytic normochromic anemia, rouleaux
Formation = stack of coin appearance = stacking of blood cells.
	
Step 3. Check nose.  Is it present or absent.  1-surgical removal, 2-eaten away due to malignancy, 3- congenitally absent.  Missing spinous and remnants of myelogram on film, most likely surgical.  If SP is present check for vertebral lucency of spinabifida.

Step 4. Check TP.  Primarily looking for fx.  To differential fx from nonunion, with fx usually lucency is jagged with no cortical margin and with displacement.  Nonunion lucency
is usually smooth with cortical margins around fragments with no displacement.  The only time to diagnosis TP fx without displacement is if you see a bony callus.  Callus appears as bony cloudy density around bone.

AP LUMBAR –Motive=Routine Scout.
Step 1. Start at lower 1/3 of SI joint.  3 conditions come to mind - AS, DJD, OCI.  AS starts in SI joints and causes bilateral symmetrical fusion of SI joints.  Ask yourself if you can see SI joints (from lower 1/3).  Yes = rule out AS.  No = is it technical reason or pathological.

DJD vs. OCI.    Symmetrical refers to same area but not equal.  Use whitening of iliac side of SI joint to differentiate.  Blastic mets is not symmetrical.
To differentiate DJD from OCI compare color of ilium to the lower portion of sacrum of SI joint.  If ilium is OBVIOUSLY whiter the diagnosis if OCI.  
If color of ilium is SIMILAR to lower portion of sacrum of SI joint then diagnosis is DJD. 
OCI = osteitis triangularis = hyperostosis triangularis.  Seen in multiparis women 20-40 years old.  Bilateral stress hypertrophy of ilium.  Is a benign condition, which is
self limiting and self resolving.  Responds well to adjusting and utilize trochanteric belt for stability.  No positive labs.  Radiographic sign is triangular sclerosis but these are only seen in advanced stages.

Step 2. Compare color and shape of one ilium to the other.  
Alteration of shape is PFF, Paget’s, fx or fibrous dysplasia.  Alteration of color - whiter, blastic mets or Paget’s, darker is lytic mets, MM or benign bone tumor.  

Step 3. Check for Reisser’s sign.  Helps determine age of patient.  Found between iliac epiphysis and crest.  A thin black line means growth center is open and patient is under 20.  A thin white line means growth center just closed, patient is 20-30.  No thin line or signs of DJD, patient is 30-40.  Signs of DJD, patient is over 40.

Step 4. Go to top of iliac crest and draw horizontal line across.  This line should bisect L4-5 disc spaces.

Step 5. Count up lumbar spine until last set of ribs that point down and assume this to be T12.

Step 6. Count down lumbar spine checking for lumbosacral transitional segment.  If you count 6 lumbar vertebra = lumbarization of S1.  If L5 TPs are fused or articulating with 
sacrum = sacralization of L5.  If L5 TP is flattened or wider than normal = spatulating TP.  (Not only condition where this is seen)   
Sclerosing at articulation of L5 TP and sacrum = subchondral sclerosis.  Subchondral sclerosis is only seen in true joint and not pseudo joint  (L5-SI articulation would be a pseudo joint)

Inferior aspect of TP with sclerosis, radiologists say this is sacralization because TP is trying to articulate with sacrum = sacralization.

Another congenital anomaly that affects L5 is hypertrophic enlargement of TP of L5.

Step 7. Check sacrum for alteration of shape, alteration of color and for vertical lucencies.  
Alteration of shape, PFCF: Paget’s, fx, congenital anomaly, and fibrous dysplasia.  
Alteration of color - whiter is blastic mets or Paget’s, darker is lytic mets, MM or benign bone tumor.  
Most common benign bone tumor of sacrum is giant cell tumor.  
Check for vertical lucencies of spinabifida.  Spinabifida of S1 is difficult to see.

Step 8. Check L5-S1 facets for tropism = asymmetrical facet from one side to the other.  Usu L5-S1 is coronal.  if one is coronal and one is sagittal = tropism. With coronal facet on AP view, you never see joint space.  Sagittal facet- will see joint space on AP film.  No bilateral facet tropism.

Step 9. Perform square blockhead system all the way up spine.  Check disc spaces all the way up spine looking for DJD, infection and marginal syndesmophytes of AS.

Step 10. Check opposite L2 vertebral for renal artery calcification or renal artery aneurysm.  Black center outlined in white = Dr. Donofrio's Cheri O sign.
To differential calcification from aneurysm, if Cheri O sign is smaller than vertebral its calcification, if it's larger then its a renal artery aneurysm.
Renal artery aneurysm will only span 1 or 1-2 vertebra.  Aortic aneurysm will span 3+.

Step 11. Check soft tissue bilaterally from L2-4 for a half-moon shape, curvilinear calcification of an abdominal aortic aneurysm.  Abdominal aorta should never 
be seen on AP film.

Step 12. Check soft tissue bilaterally from 12th rib to iliac crest looking for gallstones, kidney stones, stag horn calculi.  
Gall stones, 90% not seen on x-ray.  Only seen on x-ray when calcified.  Gallstone is cholesterol, fat.  Appearance of gallstone on x-ray is black center outlined in white.  Seen only on right side of body, usually at L1-2 area.
Kidney stones, 90% do show up on x-ray.  Appearance is pure white, unilateral or bilateral, seen at L1-3 area.  3 major types of kidney stones: 1-calcium oxalate,  
2-calcium urate, 3-calcium phosphate.  Appearance on x-ray as black center with white border.
Gallstone located in line with middle of ilium.  Kidney stone located in line with lower SI joint.  Renal artery calcification located very close to spine at L2.
Stag horn calculi can be unilateral or bilateral. It is the calcification of the renal calices.  Differential diagnosis must be IVP study.  To differentiate IVP study from
Stag horn calculi look for outline of the ureters on film.  Yes =IVP, No =stag horn calculi.

Step 13. Check soft tissue of pelvic inlet for uterine fibroids, calcified prostate, ureter stones and phlebolithes.

FILM REVIEW
To determine displacement of fx on AP lumbar draw line along medial aspect of pedicle.  Only way pedicles can move apart is fx.
Blastic mets with lytic mets = metastatic disease
Osteitis condescans pubi - if you see what appears to be DJD of symphasis pubi = OCP.  DJD usually occurs in weight bearing joints.  In men OCP is the result of prostate surgery, in women it is the result of delivery.  It is benign, self-limiting, and self-resolving.   History of pubic pain.
Claw osteophytes - atypical DJD.  Joint spaces are often maintained.  Cortex of bone becomes continuous with osteophyte.  Cannot see DISH on AP film because it is calcification of ALL.

Ankylosing spondylitis  - radiographic signs.
1- earliest sign is Romanus lesion.  Cannot be seen on x-ray.  Seen on MRI or bone scan.  It is the erosion at corner of vertebra.
2- shiny corner sign develops when body deposits calcium at the erosion.  This is the first x-ray sign.
3- bamboo spine due to marginal syndesmophytes
4- trolley track sign due to calcification of capsular ligament
5- dagger sign due to calcification of supra and infraspinous ligaments.  Comes to point, midline.
6- star sign.  Only seen when SI joints are fused.  Usually seen in superior aspect of the SI joint.
7- ghost joints.  Used to describe the SI joints when they are fused.

Butterfly vertebra - a congenital anomaly.  Due to failure of ossification of the center of the vertebra.  Present 2 ways   1- connected in center, 2- not connected in center. 
Sagittal cleft defect - is the radiological term for midline defect of butterfly vertebra.

Congenital block - With wasp-waist deformity.  1-failure of segmentation, 2-non-segmentation.
If you see what appears to be a disc in a congenital block = rudimentary disc aka remnant disc

Knife clasp deformity - Congenital.  Spinabifida of S1 with elongated SP of L5.
On Part IV, history of painter painting ceiling leading to low back pain.  Can lead to compression over a sacral defect and sacral nerve irritation.

Congenital anomalies from most to least clinically significant.  Affecting lumbosacral spine
1- knife clasp deformity
2- lumbosacral transitional segment
3- facet tropism
4- spinabifida of L5 or S1
5- hypertrophic enlarged Tp of L5

PELVIS- Motive of pelvic view is pain or dysfunction.
Age is the biggest differential in pelvis.   4 important growth centers: 1-acetabular epiphysis,
2- ischipubic epiphysis.  Closes at age 9, 3- femoral capital epiphysis, 4- greater trochanteric epiphysis.  Thin black line, under 20.  Thin white line, 20-30.  No thin line, no DJD, 30-40.  Signs of DJD, 40+

Condition in the young
	Slipped capital femoral epiphysis
	Legg Calve Perthe’s disease

Condition in older
	Lytic mets
	Blastic mets
	Paget’s
	MM
	DJD
	Osteoporsis
	RA
	Avascular necrosis of hip
Conditions in both
	Fibrous dysplasia
	Congenital hip dysplasia

When you have a pelvic view of someone under 20 must check for slipped capital femoral epiphysis and Legg Calve Perthe’s disease.

Motive of pelvic view is pain or dysfunction.
MUST COMPARE SIDE TO SIDE
Step 1. Start with lower 1/3 of SI joints.  AS, DJD, OCI.
Step 2. Check inner portion of pelvis, periosteum and cortex.
Step 3. Check outer portion of pelvis, periosteum and cortex
Step 4. Draw line from ilium to ischium checking to make sure that some portion of the femoral head is inside acetabulum.  If femoral head is outside acetabulum must consider:
1-congenital hip dysplasia vs. 2- hip dislocation.  To differentiate
congenital hip dysplasia. Look for Putties triad = smaller than normal femoral head - hypoplastic, shallow acetabulum, femoral head outside acetabulum. Can be unilateral or bilateral.
	Hip dislocation.  Femoral head of normal size, acetabulum of normal depth, femoral had outside acetabulum.
Step 5. Determine sex of patient.
1-look at soft tissue shadow below pelvis for penis
2-upside down martini glass appearance of angel of symphysis pubis about 90 degrees = male
3-upside down margarita glass, angel of symphysis pubis about 140 degrees = female
4-paraglenoid sulci.  Seen only in female but not in all females.  It is due to the superior displacement of artery due to pregnancy

Step 6. Compare color and shape of ilium to other ilium, pubis-to-pubis, ischium-to-ischium
Alteration of shape, PFF, Paget’s, fibrous dysplasia, fx.
Alteration of color.  Whiter – Paget’s, blastic mets.   Darker - lytic mets, MM, benign     bone tumor.

Step 7. Compare proximal femoral head and acetabulum for alteration of size and color.  Differential diagnosis, DJD or AVN of hip.
Weight bearing point of hip is the superior lateral aspect.  
DJD - sclerosis of superior lateral hip joint on both sides of hip leading to decrease in superior lat joint space.
AVN only affects femoral head with sclerosis.  Superior lateral joint space usually preserved, sclerosis only on femoral head.  Does not affect acetabulum.

At any point of joint of weight bearing joint will get normal sclerosis of bone.  The BEST way to differential DJD from AVN will be thickness of sclerosis from femoral head side to acetabular side.  If thickness is GROSSLY unequal = AVN.  If relative equal = DJD.

Step 8.  Compare femoral neck and shaft to other side for alteration of shape and color

Step 9.  Check soft tissue of pelvic inlet for 1-uterine fibroids, 2-calcified prostate, 3-ureter stones,  4-phlebolithes.
Uterine fibroids vs. Calcified prostate. - Sex
Uterine fibroids = leiomyoma.  The most common benign tumor of pelvic inlet in a female.
a.  Color.  Uterine fibroids are white, calc prostate is white.
b.  Shape.  Uterine fibroids are round, mulberry mass.  Calcified prostate is round.
c.  Location.  Round white density in center of pelvic inlet = uterine fibroid. Round white density sitting on symphysis pubis = calcified prostate.
Ureter stone vs. phlebolithes.  Phlebo are calcified viens. 
Horizontal line across top of femoral head.  Small round white density above line = ureter stones.  Small round white density below line = phlebolithes.
Saddle fx. - Fx of bilateral pubis and bilateral ischial fx.
Protrusio acetabuli is the protusion of femoral head into the pelvic inlet.  Diagnose using Kohler’s line - draw line along inner portion of pelvis.  Femoral head should
NOT cross line.  If it does = positive Kohler’s line indicative of protrusio acetabuli.  Can be caused by Paget’s, fibrous dysplasia, severe DJD, osteomalacia, trauma.
Bilateral protrusio acaetabuli is Ottos pelvis.  The most common cause of bilateral protrusio acaetabuli is RA.
Slipped capital femoral epiphysis.  Usu seen in overweight males age 10-16.  Use Kline’s line to diagnosis.  It’s drawn along superior aspect of neck of femur and it should hip some portion of femoral head to be normal.  Femoral head below Klein’s line = positive Kline’s line indicative of slipped capital epiphysis.   Slipped capital epiphysis is most common type 1 Salter Harris fx.  Best diagnosed on frog leg view.  no treatment medically.  With a healed slipped capital epiphysis you see positive Kline’s line but
All growth centers are closed.   Patient presents with painless limp.  Pain referred to groin and knee with a loss of abduction and internal rotation.

Salter Harris Fractures
Type 1.  Fx line through growth plate with slippage of epiphysis over metaphysis
Type 2.  Fx line through metaphysis and growth plate
Type 3.  Epiphysis and growth plate fx.
Type 4.  Metaphysis, growth plate and epiphysis fx
Type 5.  Compression of growth plate.

Type 2 is most common.   Type 5 has worst prognosis as bone has stopped growing.
                                                    
Legg Calve Perthe’s disease seen ages 4-9.  AVN of hip in child.  Radiographic signs
1-flattening of femoral head
2-fragmentation of femoral head- crescent sign
3-whitening of femoral head - snowcap sign
4-joint space will be wider than normal.  
Can take 2 months for AVN to show up on x-ray.  Untreated AVN leads to DJD later in life.  Get patient off weight bearing activities.  Swimming is good.  

Healed Legg Calve Perthe’s disease
1-flattening of femoral head
2-no fragmentation of femoral head
3-no whitening of femoral head
4-joint space wider than normal
Radiographic signs for healed LCP is mushroom deformity.  Clinical presentation is painless limp.  Pain referral to groin and knee with loss of abduction and internal
rotation of hip.

EXTREMITIES-Motive is pain or dysfunction.  Read proximal to distal anatomically.
Step 1.  Check periosteum
Step 2.  Check cortex
Step 3.  Check medulla
Step 4.  Check joint spaces
Step 5.  Check growth centers
Step 6.  Check soft tissue

Step 1.  Check Periosteum.  Checking for periosteal reaction, which is new bone growth in response to cortical destruction. 
2 basic types of periosteal reaction:   
1-linear aka parallel aka laminated.  Think trauma or infection.
2-spiculated aka sunburst aka radiation periosteal reaction.  Think primary bone malignancy, such as sarcomas.
1-linear periosteal reaction only occurs on long tubular bones.  To determine if it is a linear periosteal reaction you must see - thin white line, radiolucency, 	cortex of bone.   Think trauma or infection.  To differentiate trauma from infection look for signs of trauma - lucency line going through bone to indicate fx line, bony callus.  Either of these signs of trauma will do.  Callus does not obliterate cortex of bone. With periosteal reaction, ask yourself is it linear.  If not then it's spiculated.
2-spiculated = primary malignancy of bone.
	3 sarcomas: 1-osteosarcoma, 2-fibrosarcoma, 3-chondrosarcoma.
	Osteosarcoma - age 10-30
	Fibrosarcoma and chondrosarcom - over age 40.
Only time you see osteosarcoma in someone over 30 is when it is the malignant stage of Paget’s.  You cannot differentiate chondrosarcom from fibrosarcoma on x-ray.
Need biopsy or bone scan to diagnosis.

If you are unsure about type of periosteal reaction, check for bony expansion.   Trauma and infection do not expand bone.  Primary malignancy of bone can cause expansion.

Ewing’s sarcoma.  Usually seen ages 10-25.  Usually affects diaphysis of bone.  To diagnosis you must see ALL 3 radiographic signs.
1-multilaminated aka onionskin appearance of periosteal reaction
2-bony expansion
3-lytic areas in medulla surrounded by sclerosis

Step 2.  Check cortex.
1-thickening.  Think Paget’s
2-thinning.  Think osteoporosis
3-interruption of cortex - Fx or nonunion
4-deformity – Paget’s vs. fibrous dysplasia
Once you have deformity on film the ONLY way to differentiate Paget’s from fibrous dysplasia is by comparing the OVERALL color of medulla to adjacent soft tissue.  
If overall color of medulla is OBVIOUSLY whiter than adjacent soft tissue = Paget’s.
If overall color of medulla is similar to adjacent soft tissue = fibrous dysplasia = ground glass appearance of fibrous dysplasia (FD).
Tibia - sabre sign deformity.  Caused by Paget’s and FD
Femur - Sheppard’s crook deformity.  Caused by Paget’s or FD
When checking for deformity in pelvis, first check shafts of femur.
Normal.  Go to lesser trochanter and drop straight line along shaft of femur.  For normal, the line must run along shaft of femur.   If line runs lateral to shaft you have bowing of femur, which is deformity.  Once you have dysplasia think Paget’s or FD

Paget’s.  Radiographic signs.
1-cCottonwool appearances 
2-Fasiculation appearances - pull cotton balls apart.  Accentuation of trebecular pattern
3-Osteoporosis circumscripta 
4-Blade of grass
5-Sheaths of grain
6-Brim sign of Paget’s.  Cortical thickening of pelvic brim
7-Pseudofractures - horizontal lucencies in shaft of long bone that appear as fractures when checking for cortical thickening in pelvis due to Paget’s check pelvic brim, pubis and ilia

Paget’s aka osteitis deforman’s usually in men over 50.  4 stages:
1-lytic phase.   2- mixed phase.   3-blastic phase.   4-malignant degeneration.  Usually oseteosarcoma.

LABS.  1-increase alk phos.   2-inc urinary hydroxyproline.   3-normal calcium.   4-normal phosphorus.

Horizontal fracture line through a long bone is a pathological fx.  Called a banana fx.
When long bone fx it usually happen obliquely.  A spiral fx.

Fibrous Dysplasia.  Darkening of medulla think lytic mets, MM, FD
A benign bone tumor.  Get cobweb or spider web appearance of FD.  "Ooh, I’m scared".
Monostatic form of FD.  Rhind sign is border of this aka Rhind of sclerosis indicative of monostatic form of FD  (vs. benign bone tumor)

                             ----------------------------------------------------------------------------------------------------------------------------End day 3

Osteopoikelosis.  Tiny white dots within bone.  Must prove other than blastic mets when you see white density in bone other than carpals or distal femur.
To differentiate from blastic mets:  1-age.   2-cortical thickening with bone deformity.  
Best way to differentiate osteopoikelosis from blastic mets will be based upon the size of the white densities.  If OVERALL sizes of white densities are roughly similar then you have osteopoikelosis.  If overall size is GROSSLY different you have blastic mets.  Keep in mind some small white densities may join to form large mass.  If you are unsure about the size of the white densities then and only then check to see if almost every bone on film is affected.  If almost every
bone on film is affected, you have a systemic or metabolic condition and osteopoikelosis is a systemic condition.

Synoviochondrometaplasia.  Aka synovioosteochondrometosis.  It is white popcorn line calcification IN a joint AND around joint.  Must consider capsule. Primarily due to DJD or trauma.

Myositis ossificans.  Is calcification or bone within muscle.  To differentiate from synoviochondrometaplasia, look to joint.  If in the joint, you have synoviochondrometaplasia.  
Not in joint you have myositis ossificans.  Cause is blunt trauma where you get a hematoma formation.  Most commonly seen in biceps and quads.

How to differentiate spiculated periosteal reaction of primary malignancy of bone - sarcoma.
1-best way to differentiate is motive of film.  Underpenetrated film, go to myositis ossificans.  Bone film; go to periosteal reaction of primary malignancy of bone.
2- with myositis ossificans calcification is usually parallel to shaft of bone.   Periosteal reaction of primary malignancy of bone is 90 degrees to shaft of bone.
3-with myositis ossificans you will see a radiolucency between the calcification and the shaft of the bone.

HIP JOINT.  Primarily looking for 5 hip fx or 2 avulsion fx.
Intracapsular
1-subcapital fx
2-midcervical fx aka transcervical fx
3-basocervical fx
Extracapsular
4-intertrochanteric fx
5-subtronchanteric fx
1-3 are intracapsular, 4 and 5 are extracapsular
2-midcervical aka transcervical fx is most common
4-intertrochanteric fx is second most common.

Avulsion fx
1-greater trochanteric avulsion fx.  Displacement is usually superior.  Muscles primarily affected are the glut medius and the glut minimus.  Leading to decrease abduction and internal rotation.
2-lesser trochanteric avulsion fx.  Displacement is usually medial and superior.  Muscles primarily affected psoas.  Leading the decrease hip flexion.

KNEE

Differentiate medial from lateral side.  Medial is the weight bearing side.  Medial condyle usually projects more inferior.  Adductor tubercle is only on medial side.  Medial is larger.  Most conditions of the knee diagnosed on AP.  When you have decreased joint space in the knee the intercondylar eminence will be jammed up into the intercondylar fossa such that you cannot see a space between the eminence and fossa.
1-DJD vs. RA of the knee.  3 board scenarios.   
1.  Loss of medial joint space, subchondral sclerosis and if severe enough lipping and spurring with lateral joint space is preserved = DJD.
2.  Loss of lateral joint space but medial joint space is preserved.  This is indicative of any other condition other than DJD.  Most likely RA.
3.  Loss of both medial and lateral joint spaces.  To differentiate DJD from RA check for OBVIOUS subchondral sclerosis on both medial and lateral tibial plateaus.  If you see OBVIOUS subchondral sclerosis of both medial and lateral tibial plateaus with loss in both joint spaces = DJD.  If subchondral sclerosis is only on medial or lateral with loss of both joint spaces = RA.

2-Osteochondritis dessecans.  An avascular necrosis of the distal condyle of the femur.  80% on medial, 20% on lateral side.  Black crest sign must be seen to diagnose osteochondritis dessecans.  Also referred to osteochondral fx line.  If bony fragment dislodges this is a joint mouse.  Multiple fragments are joint mice.  Do not need to see bony fragments to diagnose osteochondritis dessecans.  Before you diagnose a film as normal or DJD of the knee check condyles one more time for a possible osteochondritis dessecans.  Lateral aspect of medial condyle that is affected.  Best view to see this on is tunnel view.  Classic history, 17-30 year old athlete complains of locking of the knee on extension.  Can take 8 mos - 2 yrs to heal.

3-Pelligrini Stieda diseases.  A calcification of medial collateral ligament.  Most common cause DJD and trauma.  More seen on femoral side than tibial side.  Wisp-of-smoke' appearance.

4-Charcot’s joint aka neuropathic joint aka neurotrophic joint.  It is a hypermobile, painless joint usually in weight bearing joint.  Most common at ankle, foot and knee.  Any condition that interferes with the sensory input between a joint and the brain can cause a Charcot's joint.
6-Ds of Charcot's joint: 1.destruction, 2.dislocation, 3.density increase, 4.debris, 5.disorganization, and 6.distention.
Density increase is due to bony debris.  Must see a bone film to diagnose a charcot's joint.  Can be caused by 1-diabetes mellitus, 2-tabes dorsalis, 3-neurosyphillis, 4-leprosy, 5-repeated corticosteroid use, 6-alcoholic neuropathies.  Appears as bomb blew up in joint.

Osgood-Schlatter’s disease.  Must see lateral film of knee to diagnose this.  It is a post-traumatic avulsion fx of the tibial tuberosity.  Usu age 10-16.  Repetitive microtrauma.  Due to repeated contraction of quads.  Most common sport seen in soccer.  Management 1. Stop activity for 3-5 wks, 2. Osgood-Schlatter’s brace, 3. Swimming, free-style.  Not really an x-ray diagnosis.  More a clinical diagnosis.  Must have pinpoint pain over tibial tuberosity.

CPPD aka psuedogout aka chonrocalcinosis.  Fine linear calcification of the hyaline and fibrocartilage.  Most commonly seen in the knee.  Calcification of menisci.

Fracture vs. Nonunion of patella.  1-transverse fx of patella, 2-stellate (star-like) fx. Nonunion only occurs in areas of growth centers.  Normal growth center of patella is upper lateral aspect of patella.  If you see what appears to be an open growth center on the patella and all other growth centers are open then you are dealing with a normal open growth center.  If all other growth centers are closed then you are dealing with a nonunion.  Nonunion can present in 2 ways.  1-if you see 2 pieces = bipartite patella, 2-patella in 3 pieces = tripartite patella.

SKULL.  3 major conditions: 1. Paget’s, 2. Lytic mets, 3. MM.  
1.  Paget’s.  To dx Paget’s in the skull you must see cortical thickening going all the way around skull.  Normal anatomy of skull is skull is thicker in back.  Watch for frontal sinus.  Paget’s disease of skull has occipital thickness similar to thickness of cortex in front of skull.
2.  Lytic mets and 3. MM.  With both you will see multiple lucencies in skull.  To differentiate compare OVERALL size of holes.  If the overall size is roughly similar in size = punched-out lesion appearance of MM.  MM of skull is 'raindrop skull'.  Overall size of holes are grossly unequal = lytic mets.
Remember, small holes may coalesce.  Must compare all holes. 

Bone infarct aka Caissons disease.  Scuba divers and diabetics are most likely to get this.  An AVN of medulla of cone.  Serpigenous like (snake-like)
calcification.  Dr. Donofrio describes are 'chewing gun sign'.

ANKLE/FOOT-Motive= Looking for fractures and arthritities.  
Everything in foot applies to the hand.
Most commonly fx bone in foot/ankle is fibula.
Potts fx - fx of distal fibula with ligamentous disruption - widening.  As soon as you see distal fibular fx, diagnose Potts fx.
Bimalleolar fx. Distal fibular and tibial fx
Trimalleolar fx. Distal fibular, distal fibular, posterior aspect of tibia.  Must see 2 views to diagnose this.
March fx. Fx of the 2, 3, 4 metatarsal
Dancers or Jones fx - fx of 5 metatarsal.  Radiolucent line INTO shaft (not vertical).  Normal growth center of 5 metatarsal is vertical.

Arthrotides of foot and hand 
PA FILM OF HAND OR FOOT.  Process of reading film changes.
Step 1.  Check mcp or mtp
Step 2.  Check pip
Step 3.  Check dip
Step 4.  Check carpals or tarsals
Step 5.  Check periosteum
Step 6.  Check cortex
Step 7.  Check medulla
Step 8.  Check joint spaces
Step 9.  Check growth centers
Step 10. Check soft tissue

4 major arthrotides affect hand and foot - RA, OA, PA, and Gout

Step 1. mcp/mtp - RA.  When RA affects this area it affects in a distribution pattern.  Destruction from joint to joint is relatively equal.  RA can cause deviation of the phalanges toward the ulnar side of hand or fibula side of foot in a distribution patters = Lanois deformity - ulnar/fibular side deformity.  Haggard’s nodes at mcp/mtp.
Must see 3 or more same joints affected for distribution pattern of destruction.  Will see juxta-articular osteoporosis - darkening on both sides of joint.
Rat bit erosions aka marginal erosions.

Step 2. PIP - RA, OA, PA, Gout.  All can affect pip joints.  Bouchard’s nodes appear at pip joints.  These are unspecific to any condition.

Step 3. DIP joints - RA NEVER involves dip joints.  If dip joints are involved in a distribution pattern think OA vs PA.  To differentiate OA from PA look for color of the center of joint.  If color is whiter = OA.  If color is darker = PA.  Heberdon’s nodes at DIP pathopneumonic of OA.

Psoriatic arthritis. For boards look for mouse ear sign, pencil in cup deformity, balancing pagota sign, cocktail sausage digits, ray sign.

Gout.  70% of time gout is mono-articular.  Love to affect the big toe = podegra.  30% of time affects multiple joints.  No distribution pattern.  Destruction from joint to joint is usually grossly unequal. ONLY ARTHROTIDE THAT DESTROYS FROM THE OUTSIDE IN.  Joint space is preserved until advanced stage.
For Part IV - overhanging edge sign and juxta-articular erosions.

Siever’s disease.  An AVN of calcanial epiphysis.  Turns whiter.

Boehler’s angle is used to diagnose calcanial fx.  Usu impaction fx.  Normal angle is 28-40 degrees.  Draw dot at middle of calcaneous and posterior of calcaneous -draw line.  Middle to front, draw line.  Increased angle = congenital malformation.  Decreased angle = fx.

Heel spur.  Most common cause if plantar fasciatis.  Reiter’s syndrome can also cause heel spur = lovers heel.  Reiter’s is caused by Chlamydia.

SHOULDER 3 views, AP internal rotation, AP external rotation, and baby arm/lateral.
If you see a baby arm/lateral film you can rule out fx, dislocation and separations.
99% of diagnoses of shoulder will be off AP view.  When given a shoulder view, ask yourself 'what joint can I see better?' that's probably where problem is.

8 STEPS TO PROCESS.
Step 1. Trace clavicle off film from lateral to medial checking for vertical radiolucencies of fx.  Horizontal lucency is a mach line.  Displacement will be seen with fx.

Step 2. Check for AC separation.  Draw line through distal clavicle.  Should hit some portion of acromion to be normal.  If it doesn't hit SOME POINT of acromion you have an AC separation.  Coracoclavicular ligament is affected. 

Step 3. Top of coracoid process and move lateral to find top of glenoid fossa.  May be overpenetrated.

Step 4. Draw horizontal line at top of glenoid fossa. Check for 25% or more displacement about or below that line to indicate a glenohumeral dislocation.  Take in to account angulation Put dots at top and bottom of fossa, connect with line and draw perpendicular line to hat line at top of fossa.  Measure amount of displacement from line to tope of humeral head. Split fossa into quarters.  Reference is fossa.

X-ray Review: Dr. Joe
After Ilyne left

Hill Sachs 
•	Aka Hatchet deformity
•	Erosion usually of the superior aspect of the humeral head
•	First sign of chronic dislocation

Bancart Lesion
•	Second sign of chronic dislocation
•	Avulsion of inferior aspect of the glenoid labrum, usually due to the pulling of the long head of the triceps on the bone
•	Long head triceps: originate of the inferior aspect of Glenoid labrum

Step 5:
•	Check periosteum, cortex & medulla of the humerus
•	When a long bone fractures- remember 2 or more pieces of bone is a Comminuted Fracture

Step 6:
•	Check the middle of the Glenoid fossa for radiolucent line coming into the fossa
•	This is a Glenoid Fossa Fracture = Scapular Fracture
•	Foosh: Fall on outstretched arm: Mechanism

Step 7:
•	Check periosteum, cortex, medulla of scapula

Step 8:
•	Check the ribs on the film
•	The ribs on an AP shoulder, will be read exactly the same as the ribs on a spot shot of the ribs
•	NEVER, make a lung pathology Diagnosis on any other film than a chest film
•	You will never see periosteal reaction coming out of a joint.  There is no periosteum in a joint.  Periosteum is pain sensitive so Mother Nature wouldn’t want that in a mobile joint.

HADD: Hydroxy Appetite Deposition Disease
•	All encompassing term for
1.	Calcific Bursitis: (CB)
2.	Calcific tendonitis (CT)
•	Amino Acid, proline, associated with a CT issue.  Take vitamin C for healing of connective tissue
•	Turns into Hydroxyproline, which is the cartilage of the bone
•	You can’t see bursitis or tendonitis on an X-ray, only the calcification of that tendon
•	Most commonly seen in the shoulder
•	To differentiate CB from CT, tell time.  Find where 6pm is before you hunt for 12 o’clock as the angle makes a difference.  7 o’clock and 5 o’clock are the shaft of the humerus.
o	12 o’clock: subacromial bursa
o	2 o’clock: supraspinatus tendon
o	3 o’clock & 9 o’clock: subdeltoid bursa
o	10 o’clock: supraspinatus bursa

SPOT SHOT OF THE RIB
•	Motive: view ribs-only, no diagnosing lung pathology
•	Biggest thing you see affecting ribs is RIB fracture
•	Most common benign tumor of the ribs = Fibrous Dysplasia
•	Most common primary malignancy of the ribs = MM (multiple myeloma)
•	Process: start at the top and come down.  Check two ribs at a time and check the interspace in between
o	Check interspaces for abrupt changes, with the 2 ribs- above and below
o	This rapid change is a fracture

ELBOW
•	What affects the elbow?  Fracture, arthritis, fat pads
•	Fat pads: 2 fat pads you need to be concerned with are the anterior & posterior.
•	Anterior fat pad: this can be seen normally.  For it to be normal, it must be parallel to the shaft of the humerus.  If the anterior fat pad gets displaced away from the humerus and it appears like the sail of a sailboat, then we refer tot that as the Anterior Sail sign, which indicated inflammation (m/c = RA) from trauma, infection or inflammatory Arthritis.
•	Posterior Fat pad: should never be seen normally.  If you see this, it is from inflammation from trauma, infection, or inflammatory arthritis.
•	Arthritides: DJD vs. RA.  Most come off lateral elbow
•	If you see a decreased joint space in the elbow, it is DJD or RA. To differentiate DJD from RA, check for obvious subchondral sclerosis on both the ulnar and the radial side of the elbow joint.  IF you see obvious subchondral sclerosis on either the ulnar of the radial side of the elbow joint, then your diagnosis is DJD.  If you don’t see any subchondral sclerosis, then it’s RA.
•	The humerus is thicker bone, will appear whiter, so will check radius and ulnar side for sclerosis, drop down a bit from the joint as thee will e some overlap of the bone
•	Pseudocyst: on the radial
•	Rule: never put down a benign bone tumor as a diagnosis in the olecranon process unless you’re willing to bet your life that its there.  
•	Juxta= articular
•	Fractures: non-union: #1 differential for fracture, and the #1 differential for a non-union is a fracture.  “Excuse me, step aside.”  
o	Olecranon Process Fracture: Displacement is the best for differential of fracture vs. non-union.  
•	Olecranon: affects the triceps as it inserts on olecranon.  Look at arm extension.
o	Impaction: Fracture of Radial head.  Occurs with a fall on it.  This actually changes the contour, as the head falls on the neck.  You’ll detect this as you check the periosteum.
o	Chisel Fracture: Also a fracture of the radial head, the patient falls on an outstretched arm.  Looks like you take a chisel and chip away at the bone.

FOREARM: There are seven fractures
1.	Nightstick Fracture: fracture of the midshaft of the ulna.  Protect self from a cop, so hold up forearm.
2.	Galeazzi Fracture: Fracture of distal third of radius with dislocation of the ulna
3.	Monteggias fracture; fracture of proximal third of the ulna with dislocation of the radial head
4.	Collie’s fracture: Fracture of the distal radius with posterior displacement of the fragment.  Radiographic sign: dinner fork deformity
5.	Smith’s: aka reverse collies.  Distal portion of the radius with anterior displacement of the fragment.  Mr. Smith is on the front porch and the collie in the backyard.
6.	Greenstick Fracture; Only occurs in young bones & you’ll see a break in the cortex on one side, with a buckling of the cortex on the opposite side
7.	Torus Fracture; Can occur in young or older bones.  To diagnose, must see buckling of cortex on both sides.  Hold hand in the lateral position, thumb (thenar eminence) always points anterior.  

WRIST:  
•	PA, PA Ulnar deviation, Oblique and lateral
•	Most common fracture: scaphoid
•	Most common dislocation: lunate
•	Draw a line through the midline of the radius.  The PA view has the line hitting the lunate, capitate.  Go through midshaft of the 3rd metacarpal = PA view
•	If you see the 3rd Metacarpal, it is deviated away from that line = Ulnar deviated view
    
Scafoid: 
1.	The fracture will be evident with a radiolucent line going through the mid-portion of the scafoid.
2.	Dislocated: you must see 2 radiographic signs
a.	Signet Ring sign: describes the shape of dislocated insignia of school markings of a graduation ring
b.	Terry Thomas sign/ David Letterman sign: widening of the joint space between scaphoid & the lunate. There is a picture of this in Yokum and Rowe.  You must see both signs to have a dx of dislocation of the scaphoid.  Use when checking periosteal and cortex of the extremities process.
3.	AVN of the scaphoid: Preisers Disease

Lunate:
1.	Dislocated: usually posterior.  For us to diagnose a dislocated lunate, you must see the PIE SIGN, some people see a pizza of a pie.  If it dislocates posterior, it appears huge.
•	Rule: when lunate is dislocated, the top of the lunate will extend roughly to the midportion of the capitate.
2.	AVN: Kienboch’s disease.  
•	Rule: When dx AVN of the scaphoid and AVN of the lunate compare 2 bones and 2 bones only.  Scaphoid to the lunate and lunate to the scaphoid.  If the scaphoid is obviously whiter than the lunate, you have Preisers disease.  If the lunate is obviously whiter than scaphoid = AVN of Lunate = Kienboch’s disease
•	There are 2 different densities of the scaphoid.  The blood flow is distal to proximal, so when comparing, notice the proximal color to the distal color.  Take the average = gray, then compare to the lunate.
•	NB ?: Mottled appearance of the lunate: mostly white, with some dark areas

HAND:
1.	Fractures: 
•	BE: Bennett’s- fracture of the 1st metacarpal (Rolando’s when comminuted), 
•	BO: Boxers- fracture of 2 or 3 metacarpal
•	BA: Bar Room- fracture of 4 or 5 metacarpal
•	Know the carpals and how to find them
2.	Arthritides:
•	RA, OA, PA, Gout
•	RA: distribution pattern, ulnar deviation, heygarth, MCP, relatively =.
•	Hayword, California: Life west in an industrial area.  Hell being in Hayword
•	MCP: HC      PIP: BO         DIP: HAY: RA never involves the DIPS
•	Gout: 70% monoarticular = podagra.  No set distribution pattern.  With soft tissue swelling. Outside to in.  Juxtaarticular erosions.  Compare color of the center of the joint to the rest of the bone.
•	Psoriatic Arthritis: Ray sign:  If you see the DIP, PIP & MCP of the same ray being affected and the destruction from joint space to joint space is relatively equal and the color of the joint space is darker and the joint is being destroyed from the inside out, then you’re looking at the RAY Sign of PA.  Any one sign is useless, so add them up
•	Scleroderma: aka. Progressive systemic sclerosis: See reabsorption of the dital tufts of phalanges.  Acroosteolysis.  You’ll see thickening of the tissue with a claw like hand.  CREST
a.	C: calcinosis cutis: Ca+ of Soft tissue
b.	R: raynods: triphasic coloring of the hand
c.	E: esophageal dysphagia: swallowing
d.	S: Sclerodactyle: claw-like hand
e.	T: Telangiectasis; dilation of blood vessels- spider like angioma

Erosive Osteo Arthritis: EOA
•	Aka; Seagull sign: m/c DIPS also seen in PIP joints:
•	Gull wing appearance

Benign vs. Malignant:
•	Encapsulated: all the way around- short zone of transition
•	Short zone of transition
•	Non-encapsulated
•	Benign: 3 exceptions: 
o	Fibrous Dysplasia
o	HME: hereditary Multiple Osteochondromas
o	Olier’s disease: Multiple Enchondromas
•	Malignancies are usually Multiple Lesions, bone pain, short & long zone of transition
•	Benign Tumors: usually asymptomatic: 1 exception = Osteoid Osteoma: encapsulated = appears to be in 1 area of the bone.  
•	Zone of transition: where does the tumor end and the good bone begin?
o	Short zone: see exactly where it end
o	Long zone: hard to see- 

MM: spine (vertebra), ribs, skull (punched out lesions), ileum

UBC: Unicameral Bone cyst: aka: Simple bone cyst: 
•	Under age of 20 years old. 
•	 Metaphysial, diaphysial, 
•	Concentric lesions (extend cortex to cortex), 
•	Fallen fragment sign: not used to diagnose.

ABC: Aneurysmal Bone Cyst: 
•	Under 20 years old, 
•	Metaphysial diaphysial, 
•	Eccentric lesions to determine of lesion eccentric, 
•	Split shaft in half: is the majority of the lesion on one side = Eccentric.  Doesn’t matter what view.

BENIGN:
Giant Cell tumor: aka Osteoclastoma
•	Greater than 20 years old
•	Metaphysial, epiphysial
•	Soap bubble appearance = Radiographic sign
•	Not fibrous Dysplasia.  Fibrous Dysplasia: never goes to the epiphysis of long bones: LOCATION, LOCATION!
Chondroblastoma:
•	Under 20 years old
•	Metaphysial, epiphysial

UBC, ABC, Giant cell & Chondroblastoma: All cause bony expansion

Nonossifying Fibroma: NOF:  & Fibrous Cortical Defect (FCD):  these are exactly he same lesion, are an incidental findings and can be differentiated by age.  NOF is over the age of 9, FCD is under 8.  Between 8 & 9: doesn’t matter.  Usually grows.

NOF: differential is ABC.  Differentiate three ways:
1.	Size; best way.  NOF small usually. ABC: usually large.  IF can’t tell by size, move to #2
2.	Check for bony expansion: NOF: no expansion.  ABC: can have bony expansion.  If still unsure,
3.	Check for scalloping inside the lesion.  NOF: scalloping.  

Hemangioma:
•	Most common benign tumor of the spine: Hemangioma: 
•	We see vertical striation sin a single vertebra; you’re looking at the corduroy cloth appearance indicative of a Hemangioma.
•	Osteoporosis: 3 or more hemangioma

Osteoid Osteoma: OO
1.	Night pain, relieved by aspirin
2.	To dx, you must see a radiolucency surrounded by severe reactive sclerosis.  
3.	Lots of whitening of bone:  Met unless prove otherwise:
o	Blastic Mets: does not cause a periosteal reaction
o	Blastic mets: does not cause bony expansion
o	Blastic mets: does not cause radiolucencies

Most common benign tumor of appendicular skeleton: extremities: Osteochondroma:
1.	Pedunculated Osteochondroma.  Always point away from the nearest joint.  Refer to as Coat Hanger Esostosis.  This is a cauliflower shape appearance: calcified cartilaginous cap.  You will only see if it is calcified, 
2.	Sessil Osteochondroma: (SOC) aka: Broad Based Exostosis.   If you see what appears to be a radial tuberosity on a bone other than the radius, most likely you’re looking at a Sessil Osteochondroma (SOC) bump on bone where a bump shouldn’t be. 
•	If you see more than 1 Osteochondroma on the same bone, change DX to HME.  Mixed P & Sessile.  M/C: @ distal femur, proximal femur, pelvis & proximal humerus.
•	M/C benign tumor of hand & foot; Enchondromas: dif dx; giant cell tumor (GCT).  Based on prevalence:  GCT: Knee, EC: Hand or foot
•	Radiographic sign for EC: more than 1 EC: Oliers Dx

NB: pick two: geographic lesion: confined to 1 area & expansile lesion. 

Osteoma: last benign: m/c benign tumor of the skull seen in frontal sinus.  Best view is the Caldwell’s sign: PA shot of the skull.  Not sinusitis

Chest: 99% of DX of the chest
Lateral chest: used for localization
NB: forced DX of hiatal hernia on lateral chest.  Better to Dx it on PA chest or AP thoracic.

Heart shadow points to the left: costophrenic angel:

Know the borders of the portions of the lung

Gastric Air bubble: Magenblase: only on the left.  THINK about it.

CHEST:
1.	Check apices side to side:  if you see white density in apices of the lung think pneumonia & pancoast tumor.  White density stays in and around the clavicle and this is pancoast tumor.  If the white density extends well below the clavicle level, pneumonia
2.	Come down and check lung side to side:  TB
3.	Check bronchus side to side:  white density in area of bronchus is pneumonia or bronchogenic carcinoma.  Differentiate this by 
•	If you see the outline of a lobe, and the outline of a fissure = pneumonia which is fluid filled
•	If you don’t see the outline of a lobe, you can’t differentiate pneumonia from Bronchogenic carcinoma on an X-ray, go to History
4.	Cardiophrenic & costophrenic
5.	Heart shadow
6.	Check gastric air bubble

When in doubt, leave it out.  When its there, its there.