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Lectured on normal anatomy

Cervical Series: medicare seriesA P,APOMNeut. Lateral,

for 5 view add obliques; (Rt. and Lft.)

for Davis Series add flex and ext. views

post traumatic most prevalentreason for flexion and extension

Neutral Ray TargetNeutral should include the base of theocciput to C7with a loss of detail in the transitionsegementC7 is hazy due to the musculatureinjuries often occur in transtion zones

Repeat the film if need be.Need to be able to seepharymx and trachea

look forhemotoma,infection andtumor

imaging protocolsCT scan is nextdue to availabilty and cost,still the dominate method with injury

Seven view Davis seriesaccesses mobility and stability.he lumbar spine napsacks to forcedisplacement to access stabilty.Look at everything. Look at intendedobservations last

What’s a quality film?

Anatomy should be enclosed in theexaminationwith the segment above and below;The transitions of any spinal segment arethe danger zones;

Must be able to see cortical medullarycontrast - big white line which is the

cortex and white mesh of trabecularbone;This standard is the legal one.

Have to be able to see soft tissues.If can’t see look under the hot light -variable amplitude light source.

Failing the hot light test -film must berepeated.If you can only see with a hot light - mustdocument

Trachea is beneath the pharynx (?)C2 7 - 9 mm is normal,

retrotracheal spaceup to 22 mm

cervical curve reversedhallmark of anatomy,spasm due to injury

Spasm- can be caused from herniation

Torticolisscoliosis in the coronal plane.They respond quickly.You can see a spasm by referral.

straight cervical curve (loss oflordosis)18% of the population has had no trauma,No c- curve vical curve - body mustcounterbalance this,Uses the lumbar spine and the pelvisthis torque prevents your posture fromfalling too far forward.

15 degrees when doing the cervical A- P (check this)Need to tilt up 15 degrees when doingthe A - P,b/c disks are oriented in this plane

When the nodes calcify ( common)don’t know if it is a blood vessel

vertebral artery calcifiedcan’t see the vertebral artery calcified onthe plain

2 things in the A - P

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apex andparaspinal soft tissues

pancoast tumorPulmonary originit is pathologically bronchiogeniccarcinoma 15% are in the apex,causes sympathetic system ablationeg. no sweating,lip droops,myiosis ( pupil constricted)assoc. w/ enostosis

enostosis def.Morbid bony growth developmed with inthe cavity of a bone orin the internal surface of the bone index

APOMangle of the jawthe gonion should beparallel to the corner of the mouth.

DensTip type 1,base type 2,type 3 intrabody,

Mock lineswatch out for Mock lineslateral retinal inhibition (brain plays trickon you)

C1 lateral massshould not extend more than 2 mm off tothe sideif it does suspect fracture.

C1 burst fracturesCanal gets bigger therebysparing the cord.Transverse ligamentmost important ligament in the body

RA - is a morning problem

OA - is a night problem

Taumatize a joint - you diminish itsproprioceptive capabilites

Flexion Cervial viewTuck the chin kdkdkd

don’t tuck the chin - will only stress C5-C6penny methodDone In health centerswhen ever a seven series is ordered thepenny method is ordered

Extension Cervical View (look up)

Oblique Cervical ViewsGood to view through the IVFchiropractic adjustment is primarilythrough the facetIVFs that you are viewing are 45 degreesoff midline,15 degrees in declination

Oblique Cervical Views45 off midline and 15 down to see theIVFstilt the tube upside against the IVF is the side that youwill receiveIVF is always pointed downlook up in Yochum

C1 and C2first 15 degrees of rotation is at C1 andC2

3 causes of IVF stenosisdegeneration of uncovertbral orapophyseal joint (AP),disc degeneration (Verticle)congenital stenosis occurs in 5% ofpatients(?)

Neuronal Plasticityneuroinflammatory insults -can result inthe radiculitis

pediclesshould be lined up andon the anterior side of the body

Pain intensitydoes not match the degree ofdegeneration

Lateral Swimmers Viewif you can’t get see C7 on the lateral

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look this up for positioningmets hangs around at transitionscan’t clear a C spine if can’t see C7

pillarpart of the apophyseal jointis that arc of bone adjacent to the boneabove and below

Right and left pillar views (cervical)8X10,FFD 40 inchesbucky gridpatient back flat against buckyhead turned fully to right or left andslightly flexed.C.R. through C4 at a 30 - 40 degreecaudad tube tilt.(Requires 3X the mAs as other cervicalviews).Place marker on side the patient is facing.2 sets of pillars to look atOrder a Philadelphia collar for the firstday of your clinic opening.

Thoracic StudyA PLateral andPA chest

Lumbar Spine SeriesRoutine A - P lumbosacral spotLateral Lumbosacral SpotRight and Left Posterior ObliqueLateral Lumbar-convexity next to the filmto do this you must look at the AP first

abdominal aneurysmaorta - deminsion is 3.8 cm at the widestpointLarger indicates aneurysm

ectatic vessel - vessel enlarged but notaneurysmal

atherosclerosis - injury to the intemaand the media

Bifurcation of the common iliacsaround L4can also become aneurysmal

Annulusouter posterior fibers are innervated

thoracic cagelimits sagittal motion as compared withthe L1

lumbar lateral spineallows you to see IVFs

sacral base anglethe sacral base angle is 41.7 + or - 7.7(In the erect posture)supine approx. 35

Bisection of L5 vertebral - anterior 1/3of the sacral plain

Dens wt. Bearing line - likely to hit theanterior 2/3 of the sacrum

Bone when stressed - will proliferate

weight bearing line of the densdrop weight bearing line of the denslikely to hit the anterior 2/3 of thesacrum

Degenerative retrolisthesis -L3 - L4 ismost common

sacroiliac ligament - the most powerfulthe body

facet tropismno senstivity on plain filmcan’t be looked for reliably

corticocorticoidsmoderate dose steroids -bone reductionin one yeardepresses immune system,

If present with a fever- read handout

Radiology- involves histopahtologicaland biochemical components

neurogenic vs. NoneurogenicMuscle spasms alter the geometry of thespinal column

pleuripotential fibroblastsProliferation of cartilage-comes fromcan later form osteophytes

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curve reverse in a lumbar spinegoes straight in the lumbar spinedoesn’t form the reversal that occurs inthe C - spine

instabilityradiographic term assoc withmeasurements ie. disc, etc.

DJD of the spine or vertebral columnsee graph on action note pages 7 - 8

subchondral cystresults from Erosion of cartilageenough to herniate synovial fluid in thebone

discogenic spondlyosis =spondylosis deformens

? combination today of handwritten,computer and action notes? not a good note day

Facet Joint imagingflexion view is the easiest way toevaluate

Know what consitutes the IVF

Entrapment syndrome3rd component is the central canal

1. lateral recess

2. foraminal enchroachment and

3. Central canal stenosis

recurrent nerveis nonmyelinatedbranch to two levelswhen they are stiumulated as stretchedas occurs with agingSx. = diffuse poorly localized pain

PLL is a very thin ligamentespec at the L5 discPLL is mechanically or chemicallyactivated

anchoring ligament at the back wall ofthe vertebral arterythese patients are more likely toexperience protracted pain from

the disc problemdescribed by Hoffman

nuclear material deep in the discantigentically unrecog material

posterior annulus - is very vascularandthis nociceptive activation will result inextreme pain

Phosphlipase A2found in high content and is found in theinflamm pathway

Prostaglandinnotorious in producing pain in theinflamm response

inflamm steps ignite theneuroinflammrepetitive injury like torsion forces willexert enough changes andpatient will experience pain

dozen or so inflamm agents havebeen foundsubstance P is an example

Substance Pactivated in the spinal cord andactivates processing in the spinal cordacts as a threshold lowethalamic and cortical centers interpretthese as pain

AllodyniaDef. Pain resulting from non-noxiousstimuli to normal skinReceptors in the spinal cordhave had their threshold lowered,pain itself can activate the pain loweringprocessstart with noxious stimulus particularly tonerve endingsnocipetion activated substance Plowering the threshold for pain

EphapseDictionary def. Point of lateralcontact(other than a synapse) btw. nerve fibers

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accross which nerve impulses arteconducted directly thru the nervemembranes from one fiber toanother

Ephapticdef. Denoting the conduction of theimpulse across an ephaps as opposed tothe synaps -

Krettner def. short circuit betweenneurons in the cordclose relationship btw - fibromyalgia andyuppy syndrome

Not only is the disc a source ofinflammation thebarrier for incoming info can be loweredor raised by eitherpain orproprioception

Ligaments and bone capsule and skinhave a receptor that constantly feeds intothe DRGand there for can participate in the aboveprocess

herniationmanipulation does not decrease thereherniation

Regarding HVLA- best guess is that thesource of the inflamm wasdegener facet or an entrapment of ameniscus which causes inflammDue to this coinnervation-patient feels itarising from the sciatic nerve This isbasis of referred pain - is looked at as amisinterpretation of the brain

Apophyseal Jointcapsule is two membranesinner lining lining is a villous like materialcartilage survives from inbibition

way to trigger is physcial activityInappropriate vector- hits the articularsurface in an uneven matter cracksand fibrillation develops andeventually the cartilage falls off -ergonomics

now that the cartilage is gone -so whatdo we do with patients ?

oral / nutrients for reconstruction of thecartilage possible but / weak

Meniscoid picture - in Bogduck

knee jointfibroadipose structure known as a kneejointif hypermobile - primary problem with ameniscoid needsto be mechanically correctedresolve the vectors to allow for therelease of the meniscus

stenosis def.ofVertebral canalIVFLateral recess (Nerve root in the lateralrecess)

neuroinflamm agentspain syndromes without compressionsubstance P

Pathomechanics of the spinebecause of the avascular way of thenucleus pulposis this substance isdesigned to fail and its failure is know as

desication - the nucleus just starts todryafter MRI studies were performed it wasfound that this desciation alreadybeginning in the teens

Bias distribution - causes annular wearthen nucleus pulposis seeps into thesecracksdissect - spreading out the nucleus

disc herniationsrarely seen after the age of 5060% of the weight bearing through thedisc and 40% through the apop. Jt.nucleus does not change shape duringweight bearing argue thissqueeze water into the end plate and itmoves back during night

patients have pain standing it is due tocompression flexion or sitting relieves

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extension -tightens the annular marginand bulge along the posterior fibers

instant axis of extension and flexionis the center of the nucleus pulposisis the key to the whole discussion - theinstant axis of extension and flexion isthe center of the nucleus pulposisThe scatter plot is less concentrated -now it is centered at the facet joint

Water cross links with the glycoprotein

picture of a discogram - this provokesthere pain with injection, serves as ananatomical tool

bulgefirst level of discal derangement is bulgedecribes circumferential exaggeration ofthe annulus

herniationthe size, shape and location of theherniation has no effect on prognosisannular fragments rupture and nuclearmaterial escapesL4 or L5 -most commonly herniated discsually lean away from side of herniationThis root is liftedbigger the herniation the more rapid itsresolutionHerniations patients can ressolve overtimesome are asymptomatic

Conus Medullaris - the termination ofthe cord

Filum terminale - is the end

Root syndrome -produceslower motor neuron disturbancesreflexdermatome andmyotome

Radiculomyopathy - hit the cord andthe root at the same timemixed presentation ofupper and lower symptoms

Caudia Equina Syndrome

Massive midline herniation is a problemat L4-5bladder and bowel symp.input - typicalwith very large herniationseither unable to urinate or are incontinentpain is very nonspecificPain - back of both thighs and legsNumbness - saddle distributionbuttocks, back of both thighs, legs, solesof feetWeakness - paralysis of feet and legs(common)Reflexes knee jerk active(L4), anklejerk (S1)absentAtrophy - both calvesNeurogenic Involvement - anal sphincterincompetencebladder sphincter dynamic obstruction36 hours rough window -beyond this isunmanagable for surgeryNocieptive Irritant -s not only mechanicalbut also chemical eg.K+, lactic acid

don’t have to have traumaincoming pain messagesnocieption is conducted through C fibersthe other pathway is processed byemotional sensors on the braintemporal lobe contains a memory ofpain (memory)limbic system the hurt of pain(sensation)parietal complex is the localization ofpain

PAG- is where the opiates hang out-drives alcoholism

Accupunture - affects the descendinginhibitory pathway ( DIP)

3 of joints in the C spineintervertebralapophyseal jointsuncovertebralare the sites of discogenic spondylosis

discogenic spondylosisa term reserved for the intervertebral disc

3 Signs of Discogenic Spondlyosisdisc space narrowing

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osteophytosis andsclerosis(D.O.S.)

Decreased thickness of theintervertebral disc space of C5-6lose the disc space you see rotation ofC5 on C6 (above on below)

In C spine- if lose disc space-the axis ofrotation goes anterior

In lumbar spine - if lose disc space -axis of rotation goes posterior

Discogenic spondylosismost common radiographic diagnosis inour practicesegmental, regional and globaldisturbances due to thisloose the disc space & forces go into thebone and bonebuilds up making it more dense onradiographic examinationcan cause microfractures

Endplate flatteneddue to degenerative remodeling frommicrofracturespatient will maintain complete range ofmotionbutintersegmental motion will be abnormal

many times the roof sags (re:endplates)

Osteophytean example of tissue changes underforces

Rostral Caudal SubluxationFirst joints don't move thenligaments in the zygo joints shorten -which results inrostral caudal subluxationas the disc size diminshes the vert.above comes down(looks likes the vert. Below is coming uprelative to the one above)

Anterior listhesisproblem w? degen.of the zygo jointsin the lumbar spine

According to Chuck concentrate onarticle that he wrote in 1989

Went on to lecture onOsteoarthritisDiscogenic spondylosisDegeneration of the fibrocartilage in thediscApophyseal arthrosis - degeneration ofthe hyaline cartilage in the facet jts

End plate - (mentioned above) flattendue to degenerative remodeling frommicrofractures patient will maintaincomplete range of motion,intersegmental motion will be abnormal

Compressive myelopathychronic degeneration of the cord

Multisegmental degenerativeAnterolisthesisinput out of the Cspine is suppose to goto the vestibular apparatusAge reduction of conduction velocityinstead taking 10 ms it takes 15 mselderly patients loose there conductionvelocity

Talked about the article that he gave usyesterday.

T1 and T2The magnitization property is called T1and T2The T2 property is the magn relaxationpropertyT2 is a magnetic interaction of theprotons in the tissue itselfimpact on body-don’t chop the bones-we bend the bonds -no damagefat is white on T1 and T2 on MRI *

water bright on T2 (CSF is almost purewater) thereforCSF is brightest on T2fat on T2 gets a little darker as comparedto T1

T2 (if)Time relaxation - (TR) is less than 1000Time echo (TE) is greater than 75

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TE >75TR< 1000therefor CSF bright white (check this)fat bright white (check this)

GRE - will always tell you that this is afast scan(not sure what study this is assoc. w/)

CT - soft tissue windowFat is black *

By controling the magnet and theradio wavesyou can identify ifferent tissue types

Radio signals - emitted from thepatient

Advanced images of CT scanfat is black on CT( fat is white on MRI in both T1 and T2)

Nerve root in the lateral recess

Myelogram (showed us)(saw) extradural defect eg.osteophyte (stenosis, and herniation dueto a degenerative disease)

Intradural but extramedullary-nerveroot lesions in the form of neurofibromaand meningoma

2 Intradural Ddx.neurofibroma andmeningoma(N.M.)

neurofibromaalways in cerebellar pontinr angleaffect cn.s 5,6,7,8vertigo, nyst, & ataxiaseen on mriusu. Adult onset except w/ those haveneurofibromatosis dzfalx & petrosal area

meningomaalways hyperintense on mrivariedclinical presentationusu. Adult but not alwaysfalx & petrosal area

Intradural Intramedullarygliomasyrinx (fluid cavity)epidomoma (grows off the filumterminale)

myelograms- are decreasing in numberdone in conjunction with CT( aka ?)MRI is taking its place

Neurofibromatosismesenchymal problemall have the potential to undergomalignant degeneration

Huge IVF Ddx.neurofibroma orhemorrhage

T2 normal water bright, fat on T2 gets alittle darker as compared to T1CSF0 - almost pure waterdesication -decrease in the normalcontent of water in the discblack - right next to the disc - iliac arteryright next to the bodyIn big vessels MRI acts like anangiogramLow signal intenstiy on T1 is cortex - itmerges with the low signal of CSF

We don’t have a lateral recess in thespineThe superior facet margins the IVF

How does a 45 degree facet come toangle negatively ?crunch on a pillar in extesionOver 2/3 of the pillar fractures aremissed on plain filmi.e pillar fract. Most frequently missedsee them on obliquesmake sure you understand intra andextra dural differentialsExradural - know differntials (?)

MRIno matter what the pulse cortical bone =black

Tree foil configuration is replaced bya v shaped patternsuspect pedicles are too short ( thesewere my words)

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can be totally asymptomatic until thecord is bumped

Canal stenosis (ratio method fordetermination)if the ratio is not one suspect canalstenosisproceedure: measure anterior to superioron the vertebral body thenfrom the posterior aspect of the vertebralbody to the neural arch

Canal stenosis (prevalence)

Congenital canal stenosis (morecommon)high instance football players

cord elongationoccurs during flexionabout 2 mm in the lower C/SJapanese first to see

DISHmust include 4 segments andsynovial component must be normalie disc space is preservedDISH and PLL ossification associatedSI jointsnot appreciable on AP spine radiographdegenerative changes result innarrowing

Trauma and arthritis - become thesame thing after a while

Ostitis Condensens illi (OCI)common in multiparus females (alsoseenin males)osteoblastic activityaway from the marginhip joint incompacitates patients-causesheart and lung dzdue to inactivity

55 or 60 yoa people start to cut downactivitiesradiographic does not indicate treatmentas far as the hip function does

medial compartment of the kneemakes a varus deformity of the legWhat s.t. structures would this be)

1.01Patellar to insertion patella bodyshould be the same

patellar altaif the patellar tendon measures longerthan the patella you probably havepatellar alta

patella has the thickest cartilage in thebody

Gave us 2 handouts

Pathophysiology of stress fractureafter fracture there is a healing responsebone healing appears on X- rays as anarea of sclerosis

spondylopysismost common stress fractureprice to pay for the athlete that doesdoesn’t comply

Osteoporotic Fracturedoesn’t call it a fracture becauseis normal part of the aging processcan’t find someone of age with out thisproblem (check this)Not a normal fracture but at the sametime it isNot pathologicalKnown as a universal disease.32 yof w/ osteoporotic fracture of thehipconsidered pathologicalPage 3 radiographic evaluation offractures

Listing C3 on C4you list the distal to the proximalif fracture radiates everything distal tothis is considered to be fragment

Angulation - convex or concavely-fracture with 20 degrees of angulation

Overriding fragmentsometimes fracture fragments override ie.where one comes next to the other

pediatric population - is no big deal

Shortening and abnormal rotation oflimbare strongly specific for pain

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more the deformity the higher the possfor fracture or dislocation

Reduction fractureover one half to one thirdbones must be pushed togetherComplication of healing fracture with castgot to be immobilized - if reductiongood and stabilzationIn a 5-6 wk.s- callus formation (bonygrowth around a fracture site)

suspect nonunionIf calcus not there suspect nonunion( not healing union)means the fracture has stabilized andbegun to heal

Ribs are never - immobilized- usu. 6- 8wks to heal but hurt long time

Clinical significance of a rib fracutreno problem unless there is acomplication like pneumothorax

What is reontgen evidence?on the inside of the cortex is ostealmembrane known as the endosteumon outside the other one is calledperiosteumIn delayed union or nonunion the fractureline may be unioned

pseudoarthrosisshould not be thereresults from the nonunion of thefragments

ways to interrupt fracture healingalcoholismmalnutrition

Bone artrophyalso known as osteoporosis -immobilization osteopenia (disuse),prompts calcium and phosporus underthe influence of parathormone

avasular necrosiseg in scaphoid bone fracture due to a fallon the outstretched hand, ischemia leadsto osteonecrosis

angiogenesisnew vascualar supply

head of the humerushas 3 main blood supplieseffusion in a joint tamponade and end upwith deprivation of blood flow and leadsto osteonecrosis

area of the impact is undergoinginduration(induration def. The process of becominghard) soft tissue trauma maybe by theend of the 3 or 4 week, can see it onradiographyaka myosistis ossificans traumatica

myosistis ossificans traumaticadiscontinue ultrasound or massagebecause it causes further bleedinguse the rice methodideopathic - why these bone cells areout in the soft tissues

DDX.for bone growing in soft tissuemets orsports injury postinjury

stress fractureproduces bone in bone

Fat embolism - if fracture a big bone eg.fracture of the femurmarrow comes out into circulationcan get caught in the pulmonary arteryopen fracture

handout on “Healing of Bone, Tendonand Ligament”

Hemotomafirst phase of the healing processif you don’t clot or form hemotoma youdon’t have the adequate framework toheal it (watch out for anticooag. Q.ustion)

Hemotoma becomes organizedmeans that the fracture gap has startedto decalcify

Repair phase - see interdigitatingfragmentmany people argue that reorganization isover and that over attempts to repair ie,

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excessive proliferation of cells to repairwhich this is one concern of bone repair

Vascular supply brings in thefibroblastscartilage cells make cartilage and thefibroblast is pleuripotenial

can make the matrix for bone cellsmakes of osteoid and chondroid matrixthey stay as fibroblasts to producecollagen

this is the reference in C for ofMesenchymal in originLetter E - this invasion is known ascallus - underline the termnow get immature form of stabilizingtissue

Next page letter H -massive callus and now at the repairativephasethe remodeling phaseIncrease activity in a fracture on x- rayfor about 2 years in an extremity

Osteoblastic activity is stress mediatedit is a pisoelectric phenomenon putstrain on bone and it will produce anelectrical potential

either osteoclasts or osteoblasts -depends on concave or convex bumpPolarity of the fields mediate the activityof the neighboring cellsBiopotentials or strain potentials -Fukada and Yasuda, Becker; concept ofthe body as a conductor

PMFs or DC currentactivates the forces recognized by theabove Researchers

Twelve Significant Signs of Trauma

Abnormal Soft Tissues:a. Widened retropharyngeal space 7-9b. Widened retrotracheal space to anoutside limit of 22c. Displacement of prevertebral fat striped. Tracheal deviation and laryngealdislocation

7 - 9mm at C2 is significant ofdislocationrespiratory problems result from this

fat stripe - anterior to vertebral columncalled the fat stripevery hard to see

If a and b abnormal then c abnormal*

Blood like water will not stay in one placeIf it can find away to move it willIf stay a long time it will eventually put awhole in them

Tracheal Deviation Case: athlete struckin trachea can hemotomabe very aware of tracheal deviation andrelated respiratory problems

Entabation Tube (ET )tube has to beplaced until the hemotoma has ressolved- called etubation

ET is not the same as ventilation

Abnormal Vertebral Alignment:a. Loss of Lordosisb. Acute kyphotic hyperangulationc. widened interspinous spaced. torticollise. Rotation of vertebral bodies

Just say the curve is increased ordecreased or reversedthe abdnormal finding in misalignment isan abnormal ligament

torticollisis the equivalent of scoliosis in the Cspine,is an involuntary response

rotation of vertebral bodiesbest stated as isolated vertebral rotation

segmental rotation of a vertebral body -can’t rotate in isolationmust alter the segments above andbelowcontinued segmental rotation will lead torotatory dislocation (check)

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Abnormal Joints:a. Abnormal middle atlantoaxial jointsb.c. widening of the apop. jts

the first 15 degrees of rotation areC1,2

Abnormal middle atlantoaxial jointsThe physiological conseq - is the fastestway to get input into the brainthe fastest way to disrupt this is inreference to the transverse ligamentRA is most common source- neverconsider this without radiography toconfirm stability20 % of Down’s Kids will have this

abnormal IVDrefers to disc and disc space specificallywidening of the IVDThe target of that particular mechanic wecan predict the possible outcomes

What would happen with extension androtation of the articular surface ?

Looked at slides - The trachea is alwaysbelow the cartilage

Bursting comminuted fracturecan cause bleeding due to an automobileaccident

following radiographic examination by achiro the person was sent to the hospitalby ambulance

Fat on T2 gets a little darker (check thisseeems to conflict w/ above)

Longest syrinx ever reported was 22segments

Pulse rate of CSF- is the cardiac pulserate

only accept 3 mm above and belowif greater tornuchal first,theninterspinous andthen flavum

Rust SignDo not flex a rust sign

hard collar and transport

GradeI Interspinous Pain on flexionput the neck in flexion and when palpatefind tenderness

Grade II - hyperflexion - increasedinterspinous space***(check this section carefully)***ihyperflexion - withnuchal injury andflaval injurysteep angulationthe limiting translation injury is 3.5unstable configuration - greater than a 11hard collar this person and transportunstable -what is holding the head onwithout any movement spontanouslydislocatefatalities have been reported with nomovementspine boards are used to transportassume a spinal injury - until provenotherwisew/o tx. is progressive kyphosiseventually become goose neckHVLA adjusting contraindicationUntreated neck fatality or permdisabilitymuscle tone resists unstableconfiguration until it is no longer sufficientmore than 2 is from a segment above tobelow is abnormalnever ever move a neck until you havedone a neutral lateralC2 and 3 facets angle downwardunlike the rest of the Cspineacute anterior herniation - when the ALLrips off the annular fibers which aredelicate - the real problem issympathetic chain ablationdue to the fact they run up along themargin

goiterous mass enlargementcan cause the trachea to deviaterotation is to the convexityAP open mouth exam. Pt. cannot rotateto one side ie.cock Robin appearence

Atlantoaxial dislocationmay present as non resolving torticollis

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can lead to destabilization of theatlantooccupital joint

other etiology for torticollisa form of distonianeuro -disorderinfantile form of torticollis

If see an IVF AP filmthen the vertebrae has rotated a bunchto allow thisthis pt. has a wrung c- spine & an IVF islooking at you

apophyseal joint arthrosiscould cause an anteriolisthesis

Bowties sign (?)dislocation (Goes w/apop. Artrosis. Ithink)

locked facetzero range of motion active or passivethink dislocationthis is a surgical reduction,is an unstable segment and itsmanagement will be stabilization

atlantodental interval5 mm in adults3 mm in childresmore important is the spinolaminaralignment

Grade III* - spinous widened & jt spaceuncoversthis is an unstable neck,stay partically intact but they pull apartthe capsule has been compromised

Grade IV and dislocationcan occur unilaterally or bilaterallymay occur with rotation and flexionforward projection of the angulationshould not exceed 11 degree angle11 degrees is a very steep angle

3.5 mm of translation - in order for it toadvance 3 mm on the line abovethere must be a dural compression *

RULE OF THREEthe cord is 7 mm in diameter

the DENS is approx 7 mm from front tobackleaving 7 mm of space 3.5 in front and3.5 behinda 6 mm ADI guarantees that the patientwill have cord compressionthe compensatory system of the cord isasymptomatic

The odds of only 1 injury from a motorvehicle is 1out of 3the average number of injuries is 2.3

This was all on a table on an overhead.

C2 and C6 - area has the most injury

Ruleslikely to have more than 1 injurymost likely 2 and 6the vertebral arch is the one most oftenhitmost are extension injuries

Clay Shovels fracture- Avulsion of thespinous process of C7

What fracture in the vertebral endplatae ?avulsion andcompression

compress the vertebral bodyFlexion & extension (check) if then inflexionwhen neck goes into flexion violentlydeceleratingwhat part of the spine undergoes ddkdkdas a rule posterior tensile, and compressthing in front like vertebral arteries

opposite in the opposite

PLL more likely injured - in flexion

patterns of dens fracturestipbaseand into the body

Locked facet is a dislocated spine

ALL can be injured -in extension

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target of injury based on mechanism

archmost likey If multiple energiessite of injuries is usu C6 & 7

differential in the ROM is responsibleevery time you see changes in the planeof biomechanicsstart to see osteophytes at T12The transitional forces change quickly

Degenerative diseasehow often do you get C7, you have tohave this, fractures hide here

Of the vertebral arch fractures number 1in prevalencemost common target zone is 2 and 6

The arch has the highest likleyhood

Most commonly injured is facet (this isthe part of the arch that breaks mostoften)

Jumping facet means dislocation

Most likely to see hyperflexion at C5and 6

Spinous on flexion is greater than 2 -indicates damage to the ligaments

See dislocation as a soft tissue injury- may have death as a outcome veryserious

Grade III facet unstablethat is greater than 3.5 mm with 11degrees being the angle

Soft tissue complications ofmusculoskeletal injurySee Table 9.9

He will submit 3 questions from thelecture todayone from the neckone from the pelvis or knee or shoulderThis is all in Yochum page 681 or684 he is now to sure

Lateral cervival is the first thing we take

look at:retropharyngeal interspace - C4 to 5 - 20is allowable and the retrotracheal space -larger than 20 blood, pus or cells (checkthese)

asymmetrical tearing that can beviewed on the AP lower cervicalset belts can make

Wide interspinous space - the intervalis the one above and the one belowgreater than a 2 mm variance

Abnormal jointsbest see differences btw flexion andextensionmay want to stop the exam

widened intervertebral diskIn the adult the endplate stays with thebody during a shearing injury

Bookend fracture of the pelvisusually have to separate one or both SIjointsintrapelvis hemorrhage is the mostcommon complication due to lacerationof a blood vessel, there can also bebladder complications usually do tobony injury, laceration at the rectum

Knee injuriessimple to biomechanical injuriesmedial joint instability

Salter Harris Fracture of the KneeMRI - is very sensitive to edema, verybright on T1 and T2 weighted images

MRI has taken over imaging of thekneeIrregular signal intensity within theproximal tibia is indicative of a tear of theanterior tubercle with tearing oftrabecular boneFacet uncapping or facet perchingdemonstrated in a flexion view dkkdkdkin T1 if you see bright white this isindicative of cord bruising and hemotomacomplication this could resolve,

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common sequele to cord trauma is asyrinxspinal canal is really in the cord intrauma this has been know to herniatethey an get a shaw pattern

MRI is great for determining asyrinx

One out of 100 people end up withheadaches for life due to sensitivity tothe contrast agent

Diastasis of a suture skull fracturecompliations headaches due topressure from hemotoma, you wouldwant to order a T2 weighted MRIWhy does the humerus go superior =

Wednesday, October 30, 1996you do not view sydesmophytes indegenerative processess ??????know the difference between thesyndesmophyte and osteophyte

The disc space is affected in DISH, bydefinition the SI joint must be okay butsome patients do not read the testbook

The only way to tip a dens is fracture itnow the different types of dens fracturesthe tilt should not be more than 3advise CTdefinite if it is 5If base is fractured type I, mostcommon at 65 % look up type IIIReformation or reformating is theprocess of lifting up a view and placing itby itself

You fracture bones before you takeout the transverse ligament

The more the listhesis the more likelythe injury

Thursday, October 31, 1996

study trauma it is the core of theexam

Table 4 “Fingerprints” of vertebralinjury

1. Flexion 1. compression,fragmentation, burst vertebral bodies

2. Teardrop fracture3. Wide interspinous spaces4. anterolistheses5. locked facets6. narrow disc space this

is acuteWould you expect disc herniation to

anterior or posterior in flexion injuriesposterior

II. Extension1. Wide disc space2. triangular avulsion fracture- can

occur in flexion or extension3. retrolisthesis water seed

example- if extend enough it will drivethe dislocation posterior questionwording

4.neural arch fracture-50% this isthe most common fracture of C1

anterolisthesis with normalinterspinous space and spinolaminarline done through a neural archfracture orunilateral facetal dislocation

III. Shear1.Lateral distraction - distraction

means you have torn enough to have agrade III -the facets can be next to oneanother

2. lateral dislocation -Transverseprocess fractures

IV. Rotational1.Rotation2.Dislocation

Facet/pillar fracturesthe neck cannot sustain rotational

forcesmost victims of air crashes are

killed by facet dislocation due toabrupt impact

patients who have cervical spine injurypillar angles should be at 45 degreeslook up a pillar vie

Locked Facet, dislocation grade IIIdislocation - facetal unilateral

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In an acute setting the cord bleeds veryeasily

Next slide multilevel congentialstenosis the person doesn’t have alamina, no spinolaminar junctionCalled Congenital Spinal CanalStenosis

achondroplasiaThe cord in this patient is alwayscompressed - ever since birthDiscussion went to achondroplasiano extension moves with these patientsnever be able to determine this w/aclinical exam alonenot that the lamina is not there but it istoo short

Rugby and Football playersthis was reported early on in Rugby andFootball players5% of general population and up to 30%in these individualsthis cord looked like the oscar miarwenor sausagecortex is very dense crystal & waterdoesn’t move around well

Next slide high signal intensity inthe cordchordoma - nothing to do with the cordt is a tumor of the nucleas pulposisthis slide was hemorrhage or contussionin a week her leg stopped working, howdo you determine the differnce from asyrinx

chordoma vs. Syrinx DDXtypically a cervical spinal injury flexionand extensionsyrinx can develop 18 to twenty monthsafter the injury

contusion is only edema in the cordsenseis occurs almost instantlywhich has a better prognosis -contusionor hemorrhage - the bigger the loss ofblood to cord or brain the greater theinjurywould know something 48 hours

the bigger the herniation -the faster theyusually resolve-

if neural signs are unrelentlyworseningthere is zero prognosis and the outcomeof the caseknow there is a herniation and there is asoft tissue casemore complex requires higherfrequency of care

Friday, November 01, 1996

Criteria for joint injurysecondary ossification centers are notpresent in a 10 year oldunderstand pseudosubluxation ofchildhood

The base of C2 can still be fracturedwhile it is cartilaginousBecause of the high range of motion inthe children in the upper C/S they gethurtAAP RecommendationsDown’s SyndromeIf atlantodental interspace is 4.5 nosports and if the they have neurologicalsigns this is even worseRole of radiography in ruling outinstabilityit is not very sensitiveFusion - interwire stabilization is notalways effectiveany patient undergoing HVLAshould have same studiesAngiogram - showed us a digitallysubtracted angiogramThis is the normal calliber of the vertebralarterysegmental narrowing of the vertebralartery atheroscleosis, dissectinganeurysm, or spasmThe cord has a period of 72 hoursThis vessel recovers withoutcomplicationThe sooner the patient is treated withthrombogenics the better the outcomeomen under 40 with hypertension and onbirth control are in danger of having aproblem especially those who aredizzyCerviogenic dizziness

17

look for the risk factors in young not oldpeopleT/S compression fractions can occurin flexionsevere cord injury can result fromthoracic spine fractureScheurermann’s Disease anteriorvertebral wedging of 5 degrees of morebetween three contigous bodies inworst case senario it produces a permkyphosis

increased growth hormone defectivedkdkkdkdk

Your posture and your additudes arelinked

you see schmorl’s hernations thisis the most common herniation it goesthrough the growth plate

If you knock off a piece of cartilagecan be termed a limbus former pieceof cartilage that looks like a fractureit matures next to a schmorl’s node

hyperextend the T/S they have touse isometric exercises

55 degrees of angulation considera brace they are developing a point inthe T spine

every day cases of schermann’sdoesn’t warrant this

Rib fractures hang around theflank Ap compression or blunt injury, ifa blow strikes from the lateral aspect youcan develop a pneumothorax

Typically impact fractures are theones you have to worry about

decreased breath sounds andlaborous breathing

lung field density in a pneumothoraxwhite line representing the pleura, so apneumo will produce a visceral pleuralline outside which can have hair

impact blows to the chest fallsdown steps, will give rise to abdominalpain

laceration of spleen and liveravulsive types are less likely to do

thatAfternoon Hours

Gastritis biospy using anendoscope to guide us in this is theway to have a defin dx

Only 15% of the patients withhelicobacter gastritis go on to producepeptic ulcer disease

The H2 inhibitors do not work acceptfor symptomatic

Cytomegalovirus increasing causeof gastritis

includes HIV poplulationburns develop high inidence of burnsPatients with significant portions of

the body burns develop gastritis in veryhigh percentages

the percentage has to be over 15%he thinks

normal tissue, or irritation to normaltissues

3 types of acute gastritis actionnotes page 21

signs and symptoms of gastritisthese 2 conditions are more likely to

produce a positive hemoccultif they vomit might see bright redanorexia appetite suppressedGive them food that is easy to digest

both foods that won’t delay gastricemptying no fat

soup whole vegetable stalkChronic Gastritis fibrotic

replacement3 main categories mucosal layer is

thick, areas of hemorrhagic tissueshowing through

gastric atrpohy strinking of the wholestomach

complications end stage fibrosis10% higher incidence of gastriccarcinoma

patients with achlorohydria keycomponent to developing pernicousanemia

first start with chronic gastritis withfibrotic replacement eventually leadsto pernicious anemia

Chronic gastritis tend to be lesssymptomatic than acute

We generally have a bleck prognosisin alcoholic patient may get to rockbottom

Giant Hypertrophic Gastritis(Menetrier’s Ds)

Hills and valleys thicker hills andsmaller valleys

Radiographic appearance ????much more seriousTuesday, November 05, 1996

He always asks something on theflow chart

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CG plate number 4473Roughly 2 years you have to translate

after the fracture, most cases hault afterbone maturation, this does not mean thatthey cannot become unstable

The reason they go into nonunion isthat they are asymptomatic if wecatch them we can brace them and theywill heal like any other fracture

The spondylo date has nothing to dowith automobile accident thesehappened back when they were a kid

Before the union separates too farone in twenty people have this problem,we can have a tremendous savings

If the spine is unstable it will go backinto traction

Loading you can see instabilityThursday, November 07, 1996

3 arches exist across the wrist jointlook up

3 the distal aspect of the proximal row3rd proximal aspect of the distal rowPisiform can be broken in martial

arts, can undergo necrosisCommest fracture of hand is the

scaphoid, most common dislocation isthe lunate

The hand and the wrist joint is thesecond most common radiograph in theUS, the chest film is the most common

Sclerosis with a fracture line is callednonunion

TFCC need an MRI to visualizethis, it is a little cushion or meniscus

Osteonecrosis fragment with largeis collapsing, this is known as SLACscapholunate advanced collaspe

The capitate moves proximal withevery flexion of the wrist like abattering ram of a particular ligament Idid not catch the name

Negative ulnar variance whathappens with ulnar positive varianceraises risk for degenerative changes ofTFCC

These complications all arise frommechanical impact of ulnar deviation

TFCC triangular fibrocartilagecomplex

TFCC is stabilizer of the ulnar side1.2 mm radiographic dx creates a

big problem for carpal bones and TFCC

Bayonnet weapon which is acutting edge is is a congenital variationor due to posttraumatic injury

major joint injuries of the wristcarpal action with injury

Dorsal Perilunate Dislocationclinical pearl 10 days to surgicallyhelp these people or the problem ispermanent

We want collinear alignmentMust remember the three archesWhen the arches are broken you

need consultation right awayThere is a ten day window for dx of

the wristFriday, November 08, 1996

Three lines of mensuration that applyto injury, can’t leave wrist painundiagnosed

Detection or the sensitivity dkkdkdMRI or CT two camps on this issueBone scan very safe dose

comparable to a 5 view lumbar series onold screen

osteoblasitc activity increasesmetabolism and blood flow this is whyit is hot on the bone scan

What is the agent usedtechnectium 99

How does the isotope tag itself noone knows

In carpal tunnel syndrome you wouldexpect the thenar to be smaller due toatrophy

If you put a manometer spike onflexion and extension

A hypoxia in a nerve triggersinflammatory biproducts

A root inflamm syndrome mayproduce a double crush syndrome

What ligament stabilizes the thumbThe ulnar collateral ligament

The number one ambulatory fractureis that of a phalanx

Showed a picture of a fracturedislocation

More than 10 degrees of articularfracture ortho consultation

cartilage disruption is the basis fordelayed osteoarthritis

Showed us a picture of a salter harrisfracture I

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The most common fracture in the 410 age range in the radius is a torusfracture it is a significant fracture

Torus is a type of impaction injuryCarpal injury is spared when the

radius fracturesRSD due to a nonunion colle’s

fractureEponym named after Sudeck

Sudeck’s atrophy for RSDThe repetitive microtrauma

avulsion of the medial epicondylepiphysis

If joint doesn’t fit properly unevenwear and tear

This joint can’t ever be normalTuesday, November 12, 1996

Talked about skull radiographyMost of the time on the internal table

skull or the membrane the membraneis going to move the bleedingpressure is 120 mm of mercury brainis moveable jelly

stroke is a parenchymal problemThe malginancies that go to the skull

go to the femur think blastic and lyticof the femur

Infection or neoplasm may effect theskull

Both Paget’s and Fibrous Dysplasialikes the face

Osteoporosis Circumscripta1 in 10 patients have Paget’s after the

age of 60Stroke is a heart attack of the brainSudden loss of postural tone or TIA

is an ominous precursor of possiblestroke

24 hours is the time period forneurodeficit in TIA

phosphates have a direct impact ofcalcium uptake

Headache and neural deficit = strokeFriday, November 15, 1996

Skull X Rays on the overheadShowed a radiograph of an 8 year old

with fibrous dysplasia, with involvementof the ethmoid sinus

Like Paget’s Fibrous Dysplasia isalso a bone softener

Management is only for complicationsthere is no management of the process.

Next slide OsteoporosisCircumscritpa the headaches comefrom the first stage of Paget’s

Bone turn over is abnormally highType of dementia assoc with Paget’sNext Phase is blastic or mixed

phaseThe third phase is the cotton wool

appearance occurs around the pelvisalso

Problem is basilar invagination.Basilar invagination is the point of

the hard palate taken back to theopisthion

The posterior arch of C1 isocciptialization nonsegmentation ofthe C1 arch

Occipitalization often has theanomally assoc with it of basilarinvagination

Towne Projection is the forthprojection in the Skull series the bestview of the foramen magnum

This patient only has half of aformamen magnum due to foramenmagnum stenosis

Consider MRI if the patient hasinvagination to see what degree ofcompression exists

11 mm of basilar invaginationAkaline phosphate would be active in

this disorderPoorly fuzzy margin is characteristic

of cortical boneShowed radiographs women had

breast cancer, 60% have a skull mets,headache pain

What metastatic carcinoma sites arelytic rather than blastic lung, colon,kidney and thyroid, breast is mixed

Nasopharyngeal carcinoma iscommon in pipe smokers

Showed another radiographperson had headaches lots of blasticdisease these are very painful,prostate cancer was the primary

What are the lucencies those arevessels meningeal middle meningealimpressions on the inner table of theskull , this is a normal radiographicfinding

Prognathic mandible the jaw isway in under bit, the mandible withreference to the maxilla is disperic

20

The brow is very puldgy one of thefew disorders that increases the jointspace

Osteoarthtitis haunts the acromegallicThe pit gland has overgrown has

overgrown and the sella is large 14 by17 mm this is the max for normal

The sella is very senstive to pressuretwo things intracranial pressureincrease of any kind, or a pit tumor

May occur inside the pit or from apulse outside

Sellar enlargement or sellar erosionmay occur from sites distal

When the CS is performed alwaystake a look at the sella, once a year wewill pick up a sella tumorTuesday, November 19, 1996Skull 409 87pages 1151 and 785 sequence soft tissues, skeleton,central shadow, hila and lung fields

soft tissues refers to structures onand not in the chest

region of soft tissue in the cervicalspine

everything around both sides of thepatient comes into scrutiny

Calcifications are seen in the neckAxilla calification nodes calcify due

to old infectionsoft tissue nodes around the chest

and not in the chestSometimes after carbonated soft

drinks can elevate the lefthemidiaphram

Carbonation is in the fundus of thesoft

by definition there will be torque inthe spine of a scoliotic

Each of the ribs are examined insuccession

every time you do a search patternyou will superimpose the ribs on them

Mediastinum cavity is broken down3 compartments the anterior mediais from the retrosternal space to thepericardium every thing btw the sternumand the heart most fat, vessels andnodes, arteries and nerves in thiscompartment , middle mediastinumback to the anterior one third of thecolumn remaining two thirdsconstitutes the posterior mediastinum

middle mediastinum heart, greatvessels, esophagus, pulmonaryvessels

Look up the structures of themediastinum

Right side of the heart is right atriumThe right ventrical is really the right

side of the heart that ventrical drainsinto the pulmonary trunk or pulmonaryconus showed us branches of thesearteries

The left pulmonary artery is higherthan the right if right higher than theleft it is assumed to be the result ofatelectasis pulling the vessels upward

Blood has the same density of wateror the heart on a CAT scan thedensities are very different

The eye can appreciate 32 shades ofgrey

The computer can separate out 2000shades

The ascending aorta gets bloodfrom the left ventricle which receives itsblood from an artery or vein peculiaraspect of the dkdk

L4 into the common iliacs this isthe order of the aortic posticiotn and thenit goes to the aorta as we age all ofthese relationships change withoutevidence dkdkd, increase in BP iscompensatory for a decrease in strokevolume

Tortuosity the aorta on theascending side will acutally swing outbefore it comes through this is not ananeurysm this is an aging changewhere the aorta is attempting tostraighten like a hose see this on allpeople depending on there hx

The older the patient gets the moreprominent it becomes

The mediastinum should be onehalf btw 50 55% is the width of theheart shadow in an adult

This pump beats 2 billion in a life timelike any muscle in the body it must beconditioned it has extreme benefits forcardiac function the blood supply tothe heart comes off the aortic sinusthis is due to failure of perfusion thisis the basis of the leading cause of deathin the US

21

every 20 seconds some drops deadof a heart attack

collarterals grow and keep the personout of trouble until they becomedisease

E stress good news can be asource of problems must get controlof the persons life styles

Starving myocardium under the strainhypertrophy until these patients entercardiac decompensation arises byenlarge from reversilbe events

Cardiac failure without sufficientmultiorgan failure

Clavicel the more asymmetriy theribs are in an oblique postition and theribs are rotated.Wednesday, November 20, 1996

Continued with the chest x raysearch sequence

Second phase is skeletalThird central shadowForth is the hilumHilum vessels and nodes, the most

common cause of death due to cancer inthe US is bronchogenic carcinoma

One of the many phases ofbronchogenic carcinom 15% occur inthe apex

2 3 cm soft tissue density is locatedin the lung field, is always an anomalousfinding

If nodes lumped together it iscalled hilar adenopathy

Metastatic disease may produce hilaradenopathy

Bilateral adenopathy is typciallyinfectious in origin

Bilateral hilar adenopathy of equalsize and peritracheal these arestructures seen on a T spine examThis is the 1,2,3 sign, indicative ofsarcoid look this up

Bilateral asymmetricallymphoma is in the differential

The presence of sarcoid theenzyme renin angiotensin ACEis elevated in sacroid, but many patientsgo to biopsy

Hilum gets a lot of attentionIf patient has a dense hilum and it

is not adenopathic whats leftvascular disorder like pulmonary

hypertension causes increase size ofthe vessels

COPD above is a common findingThe alveolar walls degenerate the

capillaries in the interstial wallsdegenerate

COPD is hard on the heartSmoking causes a depression of the

bodies anti inflamm mechanismsprotein distruction follows in the wake

of protein destruction, the heart getslarge on this side and will eventuallyspread to the other side

What is the most common cause ofacute kdkd pulmonary emolism thepatient has a few hours and then deadthey look like they are having heartattacks kills 40,000 people a year

look up the definition of cor pulmonaleThe parietal and visceral plura move

with breathingfluid is something similiar to synovial

fluidIn the 5 phase we need to cover

the entire plural surface along theedges of the ribs and scan across andlook at density the density leaves thechest wall

Consolidated Lung the densityshould be semetrical

the Horizontal fissure is seen in theanterior rib, it is the only fissure seen in tdkdkdkdkdk

If it elevates it becomes visiblebecause fluid raises it up ateletasiskeys on the horizontal fissure not seenon the image

When we look on the search lookfor abnormal decrease look for thepresence of a soft tissue density

metastatic disease pulmonary,third is granulamatous diseasetypically histomplasmosis

the above is the differnetial for a solidpulmonary nodule anywhere in thelung

Pulmonary mass is greater than 3 cmbronchiogenic carcinoma, metastasisand infection this is the big brother ofa pulmonary nodule

Threats from the heart arrthymia ,the vasculature to the heart and thevalves and muscle to the heart these are

22

the problems we will all some day facewith the heart

Mammography this examination isthe only means by which breast cancermay be

palpation skills best skills at this isa gynocologist palpation is still 2years behind dx by radiography bycongressional law these can beperformed on demand that ismammograms use to be doctor had tosign a slip but no more

If this trend is maintained breastcancer may be a normal finding

High mass and low kvp onmammography to produce high contrastto the breast tissue

Order of 28 branches in most peoplefrom the first branch in the lungasthma blocks a massive volume of lung,tumor tends to block the segmentalbronchus right middle lobe 2segments typically under the 20 25year mark

The wastes in our environmentvessels on a chest film are from

pulmonary artery can’t see coronaryarteries on radiographs without acontrast agent.Thursday, November 21, 1996

The left pulmonary artery chestfilm from perspective sksksk

Spent alot of time on the vesselsaround the heart and lungs not sure ifthey are the arteries of the heart

They branch until they are smallcapillaries around the vein carries itback to the left atrial appendage

Subclavian artery occulsion justproximal to take off that is high gradestenosis of the subclavian artery, comesdown the basilar and then to thevertebral artery backwards and suppliesthe rest of the subclavian this isknown as the subclavian steel

Look up Steele PhenomenonPelvic Pain when walking

discomfort and dizzinessPosterior left side, and anterior is right

sideEcocardiography is ultrasound of the

heart extreme perscision can beviewed in real time uncordinatedmovements can be a big problem

Filling of the right side space rightbehind the sternum

SVC draining into the right sideAngina ecocardiography to assess

damage to the wall, andangiocardiography to look at the vesseslfo the heart

LAD called the Widow MakerMany times the first symptom is MI

often stress related and triggeredEarly Monday Morning is the greatestchance of having a heart attack stressis thought to produce emobi when arrivesat the LAD you have heart attack

occlusive changes may be spasm andembolism can differentiate the twothe patient has serious vascular disease

By the time the patient has occulsionthey are 75 percent occluded

Colateralization can be improved withexercise the patients should beevaluated with a stress test before arehab program

Rib Notching why would it notchdue to pulsitile hydodynamic pressurefrom a vessel, with beating duepressure erosion

Erosions that are saucer like due tohigh pressure in the system due tocoarctation of the aorta

Like the aorta in or at the archcongenitally, backs up into the intercostalsystem it takes years to do this

Azygous of AZ this lobe ariseswhen the AZ arises in the lung causingan invagination in the lung the AZlobe is an example of an anomalyalways cuts down in the right apexcomes from when goes down the lungrather than the mediastinum

Nothing significant the lung is justanomalous

There are 1 segments on the leftside

Right 4 upper and 4 lowerPhase of the search pattern take

heart widest on the left and rightcardiac ratio if greater than 50 %Second Hour

How is the chest studies in themediastinum CT with a contrast agent

What else can do this to ahemidiaphram atelestasis can draw a

23

diaphram up it never depresses italways pulls up

Pulls structures toward the side ofatelectasis cancer until provenotherwise in a forty year old and olderit is cancer until proven otherwise

infection or spasm can elevate ahemidiaphram

mass underneath pulls it upunilateral diaphram

Look through the heart shadowFibrous tissue and calcification old

inflammation or an old processAtelectasis means there is

incomplete inflation of the lung, becauseof obstruction of a bronchus

Scar form of atelectasis the airdistal to the obstruction will eventually beabsorbed, in that circumstance thealveoli collapse resulting in thedisplacement of structures

The direct sign is fissuraldisplacement these are referred to asdirect sign know the differnce btwdirect and indirect atelectasisatelectasis is the leading cause ofdeath due to cancer that isbronchiogenic caricoma mostcommon manifestation is atelectasis

13 % prognosis for centralbronchiogenic carcinomaTuesday, November 26, 1996

What is the worry with atelectasistrachea and mediastinum is not where itshould be

The basis for atelectasis isobstruction of a bronchiole pathway

What is signifiance of bronchiogeniccaricinoma

Tracheal displacement ahemidiaphram and the fissure

If this were a C spine examinationtrachea deviation instead of airationthis would raise consideration for a chestexamination

Contrast is an important componentto determine vascular from nonvascular

Infection more chronic istuberculosis may go months with outdiagnosis and treatment

AN opague line vein of azygouscirculation this represents the fissure,a little lobe all of its own

Eventually calcific densitiesrepresent granulamatous infectioncommon in the region

The absence of a boarder or failuresilohhette sign failure or absence of aboarder when air is replaced insubstitution of the air

Sil sign loss of a boardercontiguous with a pulmonary infiltrate

This is one of the most importantsigns in skeletal radiology

Failure to identify a boarder is a silsign

What does the arrow indicatediaphram The disparity of thediaphram from one side to anothershould not be more than oneinterspinous space

Diagnostic pneumopertioneum airwas insuflated into the diaphram

Pulmonary mass greater than 3 cmcarinoma, metastasis or abscess

Massive infiltration of the alveolarairspace by tumor

In order for clavicle to be lifted upthis is the apical lordotic position byangulation of the tube or by posture ofthe patient easier to just move thetube

Anytime a shoulder series or Tspineseries demonstrates dkdkdk PA andlateral chest should be obtained if youare sure it is there then do chestseries

15% of the time bronchiogeniccaricinoma hides in the lung apices

If cartilage calcifies it will look morepronounced and it is an incidental finding

costochondritis does not have aradiographic finding

The non smoker has a worseprognosis, because the doctor usuallydoes not think it is significant

Solitary bronchiogenic caricinoma,met carcinoma, non calcified granulomathis would be the best news

About 30 % survival rate5 phase lung search sequencecalcium is the major differentiating

feature btw kdkdkdkThere is a way to quantify the

doubling time of a lesion the presenceof an old radiograph magic number is

24

2 years greater than 2 years isoutside the hx of a growing malignancy

1 year interval is not enough timeIf only one X ray you need a CT

and a consultationsomething on the chest can appear

as if it is in the chest something likechewing gum

Mets that go to the chest reproductive,prostate testicle ovary uterus breastcancer, and lung mets to lung

Mets to the lung is what kills childrenwith osteogenic carcinoma

The right hemidiaphram phrenicnerve irritation only a part of thediaphram has a hump as a result ofpressure in the peritoneal cavity, youknow it is congenital when on the lateralit is anterior elevation, it has no clinicalsignificance need to determine if it ismoving the phrenic nerve may beimpaired

COPD flattens the diaphramthe lung has too much air and forces thediaphram downwardsTuesday, December 03, 1996Dr. Golden came in to lecture today. Thislecture has 3 parts chest radiographpitfalls

Atelectasis is one of his favoritethings

Next slide calcification of theazygous vein

Next slide large radiopague massin the lung, hard to tell if righthemidiaphram or mass, the mostdefinitive dx is intraperitoneal gas filling,if it doesn’t fill on one side this indicatesmay by tumor, in this case it wasbronchiogenic carcinoma

this was a review of Kettner’s stuffToday’s new stuffNext slide hyperinflation tends to

give you a black lung, if take picture withCOPD and you think they are overpenetrated, this slide was tissue onone side a breast was removed and theother intact side it was giving the look ofan infiltrative process

Next slide solitary pulmonarynodule and abscess are cousins ??????Turned out to be a left nipple, as thetissue density increases it appears on

the film, if overlying a rib it can look justlike mets.

a great inspiratory effort will tend toelongate the heart and it will twist, thisslide of a nipple

next slide overlap of the samestructure, blood pus or cells tumor,this was a subpulmonic effussion itlayers out in the bottom portion of thelungs, gives you a false floor for the lungfield, this turned out to be a hernia, youwould want to take them for fluoscopy toobserve there breathing can actuallysee diaphragmatic motion

diagnosic for hernia of abdominalcontents superiorly this can be due tophrenic nerve paralysis we will haveparadoxical motion of the diaphram, ifballoons upward and is easily seen withthe radiograph

mediastinal mass could take out partof the phrenic nerve

right diaphram is usually 1 intercostalspace higher, if 2 or 3 take andinspiratory and expiratory reserve to lookfor change

next slide if done well a goodlordotic has the clavicle above the apices,this might be a aneurysm of one of thegreat vessels

great location is a subclavicularlocation solid pulmonary nodule

three basic bumps of the left hearyshadow aortic nobe, atrial andventricalWednesday, December 04, 1996

systemic hypertension causeswidening and uncoiling of the aorta

scoliosis the ribs are wider on theconvex side and closer together on theconcave side