Radiology

1.
FOUNDATION OF RADIOLOGY

MOST RADIOLUCENT - heavy metals are white solid
- BONE is dark grey/white
- MUSCLES, NERVES,TENDONS, LIGAMENTS, and
generally water is light grey
-AROUND VISCERA, SUBCUTANEOUSLY MUSCLE SHEATHS
and generally fat is dark grey
MOST RADIOPAQUE - TRACHEA, LUNGS, STOMACH, DIGESTIVE TRACT, and in
generally air is black
2.
CERVICAL SPINE

The normal lines of measurement values for CERVICAL SPINE are:
- SELLA TURCICA SIZE (lateral skull) diameter values AP diameter 5mm-16mm, Vertical
diameter 4mm-12mm. Enlarged sella may be associated with pituitary neoplasm or extra
pituitary mass.
- MC GREGORY LINE (lateral skull, lateral or flex/ext cervical spine) from the
posterosuperior margin of the hard palate to the most inferior surface of the occipital
bone. The position of odontoid APEX, should not lie above this line >8mm in males and
>10mm in females. An abnormal superior position of the odontoid indicates basilar
impression and atlas occipitalization is a common cause.
- ADI (AtlantoDental Interspace)(lateral neutral cervical) is the distance between the
posterior margin of the anterior tubercle and the anterior surface of the odontoid.
Minimum value 1mm, maximum value 3mm for adults and 5mm for children. Abnormal
widened space with reduction in the neural canal size in not senior people is causes of
trauma, occipitalization, down's Syndrome..
- GEORGE'S LINE (lateral cervical) is the posterior vertebral body proper line alignment.
A proper alignment signified no fracture, dislocation or ligamentous laxity.
- SPINOLAMINAR JUNCTION LINE (posterior cervical line)
- SAGITTAL DIMENSION OF CERVICAL SPINE CANAL (lateral cervical) from the
posterior surface of the midvertebral body to the nearest surface of the same
segmental spinolaminar junction line (from C1 to C7 the minimum values are 16mm-14mm-
13mm-12mm-12mm-12mm-12mm: anything below minimum values is stenosis)
- ATLANTOAXIAL ALIGNMENT: (AP cervical open mouth) the lateral margins of the
atlas lateral masses are compared to the opposing lateral corner of the axis articular
surface (to look any lateral shift). If the lateral margin of the atlas lateral mass lies
lateral to the lateral axis margin, may be a radiological sign of Jefferson 's fracture,
odontoid fracture, alar ligament instability or rotatory atlantoaxial subluxation.
- PREVERTEBRAL SOFT TISSUE (lateral cervical spine): the soft tissue in front of the
vertebral bodies and behind the air shadow of the pharynx, larynx and trachea is
measured ( minimum values are 10mm for pharynx, 5mm-7mm for larynx and 20mm for
trachea). Any soft tissue mass may increase these space, like hematoma and neoplasm.

3.
THORACIC AND LUMBAR SPINE
THORAC SPINE MEASUREMENT LINES AND ANOMALIES CORRELATED
- COBB'S METHOD OF SCOLIOSIS EVALUATION (AP spine): on the superior end
vertebra, a line is drawn through and parallel to the superior endplate. On the inferior
end vertebra, a line is drawn in the same way through and parallel to the inferior endplate.
At right angles to both endplate lines, lines are drawn to intersect and its resultant
vertical angle is measured. If the angle is <20° no treatment is required but a continue
evaluation is required for adolescent. Curves between 20° and 40° should be braced and
with more than 40° surgery is required.
- THORACIC KYPHOSIS (lateral thoracic spine): a line is drawn parallel to and through
the superior endplate of the T1 body. A similar line is drawn through the inferior
endplate of the T12 body. Perpendicular lines to these endplate are constructed and the
result angle is measured at the intersection of the lines. An increased kyphosis may be
seen in old age, osteoporosis, congenital anomalies and muscular paralysis.
LUMBOPELVIS MEASUREMENT LINES AND ANOMALIS CORRELATED
- SCOTTY THE DOG (lumbar oblique spine): we can identify the nose in transverse
process, the eye in pedicle, the front leg is the inferior articular facet, the ear is the
superior articular facet and its neck is the pars interarticularis. It's useful to see any
break in its neck, that represents a fracture in the pars articularis.
- MACNAB'S LINE (lateral lumbar): a line is drawn through and parallel to the inferior
endplate at the level to be evaluated. The line should lie above the tip of adjacent
superior articular process; if it intersects the superior articulating process, subluxation
may be present.
- VAN AKKERVEEKEN'S MEASUREMENT OF LUMBAR INSTABILITY (lateral lumbar):
two lines are drawn through and parallel to opposing segmental endplates until their
posterior intersection. The distance from the posterior body margins to the point of
intersection is then measured. If there is >1,5 mm difference in measurement, it's
present a nuclear, annular and posterior ligament damage.
- MEYERDING'S GRADING METHOD IN SPONDYLOLISTHESIS (lateral lumbar,
lumbosacral) : the superior surface of the first sacral segment is divided into 4 equal
segment, then we look at the position of the posterior-inferior corner of the L5 body.
The degree of anterolisthesis can be categorized into grades from 1 to 4: if the
vertebral body has completely slipped beyond the sacral, is called spondyloptosis.
- INTERPEDICULATE DISTANCE (AP cervical, thoracic and lumbar spine): is measured
the shortest distance between the inner convex cortical surfaces of the opposing
segmental pedicles; this is a useful measurement for the evaluation of spinal stenosis,
congenital malformation and intraspinal neoplasm, but it's better to use ti in combination
with other measurement values.
- EISENSTEIN'S METHOD FOR SAGITTAL CANAL MEASUREMENT (lateral lumbar
spine): for each lumbar level, except for the fifth, we can measure the sagittal canal
diameter, determining the distance between the posterior body (midpoint) and the
articular process line. A measurement < 15 mm may indicate the presence of spinal
stanosis.
4.
PELVIS AND LOWER EXTREMITY
MEASUREMENT VALUES AND THEIR ABNORMAL DISEASES ASSOCIATED.
PELVIS
- TEARDROP DISTANCE (AP pelvis, hip): the distance between the most medial margin
of the femoral head and the outer cortex of the pelvic teardrop. If the teardrop
distance exceeds 11 mm or if there is more than a 2-mm discrepancy from right to left
(Waldenstrom’s sign), then hip disease is most likely present.
- HIP JOINT SPACE WIDTH (AP hip): three measurements are made in the joint cavity:
superior joint space, axial joint space and medial joint space (teardrop distance). If
superior joint space is <3mm, is a sign of degenerative joint disease; if axial joint space is
<3mm, is a sign for degenerative arthritis and especially inflammatory arthritis. If medial
joint space is <4mm, usually is caused by degenerative and inflammatory arthritis; if its
value is more than 13mm is an indicator of hip joint effusion or later shift of the femur
(Waldenstrom's sign)
- SYMPHYSIS PUBIS WIDTH (AP pelvis): the distance between the opposing articular
surfaces, halfway between the superior and inferior margins of the joint. A value more
than 7,2mm for male and 6mm for female may be the result of cleidocranial dysplasia,
bladder exostrophy, hyperparathyroidism, post-traumatic diastasis and inflammatory
resorption ( ankylosing spondylitis, osteitis pubis and gout).
- PRESACRAL SPACE (lateral sacrum): is assessed the grey soft tissue density located
between the anterior surface of the sacrum and the posterior wall of the rectum.
Increased values of more than 5mm in children and 20mm in adult may be caused by
sacral destruction, sacral fracture and associated hematoma or inflammatory bowel
disease.
- PROTRUSIO ACETABULI or KÖHLER'S LINE (AP pelvis, hip): a line is constructed
tangentially to the cortical margin of the pelvic inlet and outer border of the obturator
foramen and is assessed the relationship between the acetabular floor to this line,that
normally should not cross this line. If it crosses the line, protusio acetabuli is present and
the most common causes are an idiopathic form, rheumatoid arthritis and Paget's disease.
- SHENTON'S LINE (AP pelvis, hip): a curvilinear line is constructed along the
undersurface of femoral neck and is continued across the joint to the inferior margin of
the superior pubic ramus; this should be smooth, especially in the transitional zone
between femur and pubis. An interrupted, discontinuous line is useful in the detection of
hip dislocation, femoral neck fracture and slipped femoral capital epiphysis.
LOWER EXTREMITIES
KNEE
- AXIAL RELATIONSHIP OF THE KNEE (AP knee)
-FEMORAL ANGLE is the angle formed between the femoral shaft line (through and
parallel to the midaxis of the femoral shaft) and femoral condyle lines (through and
tangential to the articular surfaces of the condyles)
- TIBIAL ANGLE is the angle formed between the tibial shaft line (through and parallel
to the midaxis of the tibial shaft) and tibial plateau lines (through the medial and lateral
plateau margins)
Values <75° and >85° for femoral angle and <85° and >100° for tibial angle are indicators
in fractures and other deformities about the knee.
- PATELLAR POSITION (lateral knee semiflexed) are measured:
-Patellar length (PL). This is the greatest diagonal dimension between the superior
and the inferior poles.
-Patellar tendon length (PT). The distance measured is between the insertion points
of the posterior tendon surface at the inferior patellar pole and the notch at the tibial
tubercle.
when PT is >20% greater than the PL, patella alta is present and it could be found in
association with chondromalacia patellae.
ANKLE
-HEEL PAD MEASUREMENT (lateral foot, lateral calcaneus non-weight bearing): the
shortest distance between the plantar surface of the calcaneus and external skin
contour. Increased heel pad is frequent indicator of acromegaly. A thicken of Achilles
tendon is present in inflammatory arthritis.
-BOEHLER'S ANGLE (lateral foot, lateral calcaneus): the three highest points on the
superior surface of the calcaneus are connected with two tangential lines and the angle
formed posteriorly is assessed. Normal values are between 28° and 40°; if is <28° is an
indicator of calcaneus fracture with displacement through the calcaneus.

5.
UPPER EXTREMITY
MEASUREMENT VALUES AND ABNORMAL DISEASES ASSOCIATED.
SHOULDER GRIDLE
- GLENOHUMERAL JOINT SPACE (AP shoulder with external rotation): measurements
are made at anterior, middle and inferior aspect of the joint; each distance is
ascertained between the opposing articular surfaces. The average is 4-5mm: it may
decrease in degenerative arthritis, post-traumatic arthritis and calcium pyrophosphate
dihydrate crystal disease (CPPD). If it's wider, it's associated with acromegaly and
posterior humeral dislocation.
- ACROMIOCLAVICULAR JOINT SPACE (AP or PA shoulder): the joint space is
measured at the superior and inferior borders: the average values are 3mm and a
decreased joint space is seen in degenerative joint disease. An increased joint space may
be caused by traumatic separation or resorption due to osteolysis in association with
hyperparathyroidism or rheumatoid arthritis following trauma.
ELBOW
- RADIOCAPITELLAR LINE (lateral elbow): a line is drawn through the center of
capitellum and parallel to the long axis of the radius and is extended through the elbow
joint. It's use in determining the presence of radial head subluxation(pulled elbow) or
dislocation.
6.
INTRO TO PATHOLOGY
CATBITES: all the pathologies that I can see from a x-ray, and the acronyms means :
Congenital, Arthritis, Trauma, Blood/vascular, Biomechanics, Infection, Tumor, Endocrine,
Soft tissue.
MONOSTOTIC: something that involve a single bone.
POLYOSTOTIC: something affecting several bones
EXOSTOSIS: a benign bony growth projecting outward from a bone surface.
ECCENTRIC: situated away from the centre
MEDULLARY: pertaining to bone marrow
CORTICAL: associated with the cortex
PERIOSTEAL RESPONSE: production of new bone by the periosteum in response to
injury or irritation (soft tissue or osseous disease); it could be benign or aggressive.
MOTH-EATEN: descriptive term referring to sharply delineated irregular patches of one
lesion, mass, colour, radiologic density, colour or light microscopic pattern adjacent to
another.
OSTEOLYTIC LESION: soft spot or hole in bone caused by cancer cells, it could be
benign or aggressive and malign.
PERMEATIVE: referred to osteolytic destruction, a lesion that spread or flow
throughout, usually aggressive and characterized by pinhole-sized lesions.
OSTEOBLASTIC: Relating to the osteoblasts; describes any region of increased
radiographic bone density, in particular, metastases that stimulate osteoblastic activity.
LIPOMA: a benign, soft, rubbery, encapsulated tumor of adipose tissue, usually composed
of mature fat cells.
STIPPLED CALCIFICATION: a calcification marked by small spots or flecks.
FLOCCULENT CALCIFICATION: a calcification that have a fluffy or wooly appearance
OSTEOSARCOMA: a malignant primary neoplasm of bone composed of a malignant
connective tissue stroma with evidence of malignant osteoid, bone, or cartilage formation.
SPICULATED: aggressive periosteal response similar to a needlelike structure
CODMAN'S TRIANGLE: a triangular area visible radiographically where the periosteum,
elevated by a bone tumor, rejoins the cortex of normal bone; it's an aggressive periosteal
response.

7.
CONGENITAL ANOMALIES & NORMAL SKELTAL VARIANTS
UNSTABLE CONGENITAL ANOMALIES IN CERVICAL SPINE:
OCCIPITALIZATION (fusion C0-C1, instability C1-C2 in 70% and C1-C2 degeneration)
DOWN SYNDROME (instability C1-C2, odontoid hypoplasia)
OS ODONTOIDEUM (failure of union of the odontoid process to the body of the axis,
instability C1-C2)
ODONTOID AGENESIS (failure of the dens to form and ossify)
NORMAL VARIANTS IN CERVICAL SPINE:
POSTERIOR PONTICLE (ossification of oblique portion of atlanto-occipital ligament that
forms an arcuate foramen that contains vertebral artery and C1 nerve)
OSSICULUM TERMINALE
SPINA BIFIDA OCCULTA (failure of fusion of two lamina centrally, is usually stable but
the subject could presents other anomalies)
BLOCK VERTEBRAE (congenital synostosis due to failure of segmentation, usually
asymptomatic)
KLIPPEL-FEIL SYNDROME (shortness of the neck due to reduction in the number of
cervical vertebrae or the fusion of multiple hemivertebrae into one osseous mass, with
limitation of neck motion and low hairline)
PEDICLE AGENESIS (always unilateral, differential diagnosis between congenital-
metastasis- neurofibromatosis)
CERVICAL RIB
OSSIFIED STYLOHYOID LIGAMENT
ELONGATED SPINOUS PROCESS
TRACHEAL RING CALCIFICATION
IT IS IMPORTANT NOT TO MANIPULATE UNSTABLE PATHOLOGIES!
An unstable pathologic anomaly is an absolute contraindication to forceful manipulation to
the cervical spine, because is extremely unstable and it's a risk for the practitioner and
for the patient too. Anyway, the measurement of ADI space is very important for a
suspicious of C1-C2 instability; maximum values are 3mm for adult and 5mm in child and it
should move on flexion or extension.
8.
DYSPLASIA, SCOLIOSIS AND SPONDYLO'S
MANAGEMENT OF SCOLIOSIS.
0-20° CURVES: in this range there is a close observation: a x-ray is taken every 3
months until the bony maturity, we expose a lot the patient to the radiation but the
curve can progress rapidly. If there is an angle progression of 5° every x-ray, we should
suggest to consider the bracing. If the angle is less of 20° but it's present a rotation or
a rib hump, I should anyway suggest to consider the bracing.
20°-40° CURVES: in this range usually all the curves use brace: the most common one is
the Milwaukee, that contrasts the progression, it prevents a lot of rotation of movement
but it doesn't reverse curves: but it's very invasive and restrictive and could cause a lot
of skin irritation. In any case, in this range of curves, bracing is indicated for all the
flexible and progressive curves and in all skeletally immature cases.
40° + CURVES: in this range usually is suggested surgical intervention, especially with a
rapid progression in immature spine, but all the surgical procedures are very invasive.
9.
INTRO TO TRAUMA
COMMINUTED FRACTURE: fracture in which two ore more bony fragment have
separated. When there is an isolated cortex fragment, it is called BUTTERFLY
SEGMENT.
NON-COMMINUTED FRACTURE: fracture where the bone is completely divided into 2
fragments.
AVULSION FRACTURE: fracture that exhibits the tearing away of bone fragment by a
forceful muscular, tendon or ligamentous pulling.
IMPACTION FRACTURE: fracture that presents a portion of bone that is driven into its
adjacent segment. We can classified it into two types:
- DEPRESSED FRACTURE: it represents an inward bulging of the outer bone surface,
very common on tibial plateau and frontal bone.
- COMPRESSION FRACTURE: it has a decreased size of the involved bone, due to
trabecular telescoping, common in the spine after a forceful hyperflexion injury.
GREENSTICK FRACTURE: it's an incomplete fracture in children, it occurs when the
bone bends, applying tension to the convex side that produce a transverse fracture with
the concave side that remains intact.
TORUS FRACTURE: it's due to a compression that forces the cortex on concave side,
outward.
CHIP (CORNER) FRACTURE: it's a form of avulsion fracture at corner of a phalanx or
other tubular bone.
STRESS (FATIGUE) FRACTURE: it's caused by repetitive stress on normal bone that
forms gradually micro fractures.
INSUFFICIENCY FRACTURE: it's a stress fracture through a diseased bone, it's a
pathologic fracture.
OCCULT FRACTURE: a fracture that gives clinical signs of its presence without any
radiologic evidence for its first 7-10 days. Scaphoid is the most common site, followed by
ribs.
BONE BRUISE: it represents haemorrhage and bone marrow edema associated with
trabecular micro fractures; it's not visible with an x-ray, but just with MRI.
PSEUDOFRACTURE: it's not a true fracture, but an insufficiency fracture or the result
of vascular pulsations. Usually it's a region of un-calcified osteoid and it's found in
association with bone-softening diseases.
STABLE FRACTURE: fracture that doesn't move during the healing phase.
UNSTABLE FRACTURE: if a fracture moves during its healing, it could produce a
neurological injury when a bone or a piece of bone imping the spinal cord.
OBLIQUE FRACTURE: it has a course of 45° to the long axis of the bone, usually on the
shaft of long tubular bone.
SPIRAL FRACTURE: it's a fracture created by a twisting movement with a component of
axial compression and pointed ends.
TRANSVERSE FRACTURE: it's a fracture runs at a right angle to long axis of a bone;
very uncommon on healthy bone, when it's normally strong, but it's very common in
diseased bone. It's a pathological fracture.
DIASTASIS: it's a displacement of syndesmosis joint; usually happens in pubic area, skull
and distal tibiofibular joint.
OSTEOCHONDRAL FRACTURE: it's a fracture through a joint surface, of underlying
bone and cartilage.
EPIPHYSEAL FRACTURE: fracture through growing plate, physis, epiphysis and/or
metaphysis: they are classified from type I to type V according to Salter-Harris
Classification.
10.
FRACTURES OF AXIAL SKELETON
CERVICAL SPINE FRACTURES
ALTAS
JEFFERSON'S FRACTURE: is a compression injury created by an axial compression that
broke the anterior and the posterior arches.
POSTERIOR ARCH FRACTURE: it's a single fracture, usually bilateral, due to a forced
hyperextension of the head. Frequent on car accidents.
AXIS
HANGMAN'S FRACTURES: bilateral pedicle fracture due to hyperextension, often seen
in car accident where there is an abrupt deceleration from high speed. It’s also called
TRAUMATIC SPONDYLOLISTHESIS because there is also a migration of vertebral
body anteriorly or posteriorly.
TEARDROP FRACTURE: rapture in anterior longitudinal ligament due to forced
hyperextension that causes an avulsion of anterior-inferior corner of the vertebral body.
Most common on C2, it's present in all cervical spine.
ODONTOID FRACTURES: classified into 3 according to their location, are often
associated with other cervical fractures: the type one is an avulsion of the tip of
odontoid process, the second one is most unstable and the most common, usually with the
problem of non-union.
FRACTURES C3-C7
WEDGE COMPRESSION FRACTURE: it's due to compression of the involved vertebra
from forced hyper flexion, like in car accidents.
BURST FRACTURE: comminuted fractures of vertebral body due compression in
combination with flexion component that causes burst of nucleus pulposus.
TEARDROP FRACTURE: like for the axis, a segment is pulled anteriorly due to a strong
hyperextension component that often causes bulging from posterior ligaments.
CLAY SHOVELER'S FRACTURE: it's an avulsion injury of spinous process that results
from abrupt flexion of the head like in car accident or from repeated stress caused by
pull of trapezius and rhomboid muscles on the spinous process.
CERVICAL SPINE DISLOCATIONS
UNILATERAL FACET DISLOCATION: from hyper flexion injury with rotation
component that causes one side facet dislocation; it's stable unless a piece of bone goes
into spinal canal.
BILATERAL FACET DISLOCATION: both side of facets are completely slipped off, it's
not a fracture.
TRAVSVERSE LIGAMENT RUPTURE:
THORACIC AND LUMBAR SPINE FRACTURES
COMPRESSION FRACTURE: is due to a hyper flexion with axial component. Usually the
body vertebral compressed has different shapes from the normal one (wedge, biconcave).
VERTEBRA PLANA: compression fracture due to a diseased bone.
BURST FRACTURES: comminuted body fracture due to an axial compression plus a
flexion component.
TRASVERSE PROCESS FRACTURES: non-comminuted fracture due to a direct blow to
TVP or a lateral injury.
CHANCE FRACTURES: occurs with flexion and distraction over a fulcrum that causes a
horizontal splitting of vertebral body, pedicles and spinous processes. Often confused
with a simple compression, it's easier to see in a lateral projection.
STRESS FRACTURES (PARS DEFECTS): more common on children, where repeated
hyperextension are more frequent, it's a pars interarticularis fracture that often has a
problem of non-union ossification.
SACROCOCCYCEAL FRACTURES
SACRAL FRACTURES: usually given by a direct fall on buttocks or associated with a
direct pelvic trauma, are divided in horizontal and vertical fractures.
HORIZONTAL FRACTURE: usually occurs on S3-S4, just below the SI joint, it could be
comminuted or non-comminuted.
VERTICAL FRACTURE: occurs in indirect trauma to pelvis, it's invisible on lateral
projection.
COCCYGEAL FRACTURE: from a fall on buttocks or a direct trauma, it's easier to see in
a lateral film and anterior displacement is comm
11.
FRACTURES OF APPENDICULAR SKELETON
PELVIC TRAUMA
ILIAC WING FRACTURES (DUVERNEY'S FRACTURE): it's due from a direct force from
lateral direction, it could be simple or comminuted but usually is stable.
ACETABULAR FRACTURES: it's due to an indirect injury that driven femoral head into
acetabulum. The most common type is POSTERIOR RIM FRACTURES (dashboard), that
usually occurs after a blow to the knee while the leg is in flexion and adduction.
AVULSION FRACTURE: it's due to a direct trauma or repetitive stress, is a separation
of bony fragment in ilium. According to where is the fracture, we can understand the
muscle involved: ASIS for sartorium, AIIS for rectus femoralis, ISCHIAL TUBEROSITY
(result of a forceful contraction of hamstring, it's called also rider's bone).
DISLOCATION OF THE PELVIS
SPRUNG PELVIS (or open book pelvis): severe injury representing complete diastasis of
symphysis pubis and the complete diastasis of one or both SI joints. Pelvic visceral
damages are probable.
PUBIC DIASTASIS: shearing separation of pubic articulation often associated with SI
joints and sacrum injuries. The normal distance between the pubic bones should not
exceed 8mm in non-pregnant adults and 10 mm in children.
HIP TRAUMA
PROXIMAL FEMUR FRACTURES: especially in elderly people only moderate to minimal
trauma like falling may induce a fracture in the osteoporotic femur. They are divided into
INTRACAPSULAR and EXTRACAPSULAR by the relationship of the fracture line to the
joint capsule.
INTRACASPULAR FEMUR FRACTURES: any fracture involving the femoral head or neck
proximal to the trochanters; they are divided according to the fracture location in
SUBCAPITAL (most common one, often impacted or displaced), MIDCERVICAL and
BASOCERVICAL. Generally comminuted, have a high incidence of non-union and avascular
necrosis due to probable disruption of the tenuous blood supply (avascular necrosis is a
possible complication).
EXTRACAPSULAR FEMUR FRACTURES: occur outside of the joint capsule and include
INTERTROCHANTERIC (between the trochanters), TROCHANTERIC (tear off the
greater trochanter) and SUBTROCHANTERIC (below the trochanters). Avascular
necrosis and non-union are uncommon complications and trochanteric fractures are
usually avulsed.
HIP DISLOCATIONS: usually the result of severe trauma, like MVA accident, they are
divided into ANTERIOR (15%) and POSTERIOR (85%).
POSTERIOR HIP DISLOCATION: occurs with the hip in flexion and abduction usually
followed by a blow to the knee, like in dashboard injury. Abduction of the thigh often
causes posterior acetabular rim fracture, to not be confused with an avulsion fracture.
ANTERIOR HIP DISLOCATION: is caused by forced abduction and extension of the
femur, that causes to the femur head, to pop out anteriorly, usually near obturator
foramen.
SLIPPED CAPITAL FEMORAL EPIPHYSIS: occurs during the adolescent rapid growth
period in heavier subjects where the big weight and pendulum movements make the femur
head to slip on epiphysis. it can be considered as a Salter-Harris type one fracture, a
displacement without visible fracture of epiphysis or metaphysis.
LOWER EXTREMITY TRAUMA
KNEE
TIBIAL PLATEAU FRACTURE: called also "BUMPER" or "FENDER" fracture, is caused
from the impact of the femoral condyles being forced into the weaker tibial plateau,
precisely 80% of times into its lateral part.
TIBIAL TUBEROSITY AVULSION FRACTURE: common in adolescent boys maybe
predisposed by Osgood-Schlatter disease, occurs with a direct blow on knee flexed when
quadriceps are contracted.
PATELLAR FRACTURE: from direct or indirect trauma, to not be confused with normal
anatomy variant like by/tri/multipartite. The most common orientation is transverse
(60%), followed by stellate (or comminuted, 25%) and vertical (15%); it could be
displaced/non displaced and avulsed.
ANKLE
MALLEOLAR FRACTURE: it could be medial or lateral, bimalleolar, trimalleolar, it's an
avulsion fracture from a rotational ankle injury.
FOOT
CALCANEAL FRACTURE: divided into non-compressive (avulsive) and COMPRESSIVE, the
last one due to a fall on calcaneus itself from a great height. Generally comminuted, can
be bilateral or associated with vertebral fracture.
METATARSAL FRACTURE: most common is JONES' FRACTURE (Dancer's fracture), due
to an inversion associated with plantar flexion that causes the transverse fracture of
base of 5th metatarsal. It's frequently non-union and overlooked.
PHALANGEAL FRACTURE: it's a common fracture due to a crush with heavy object
(comminuted), to a direct blow into the bed or into an object, to a flexion/extension
injury that caused an avulsion fracture (chip fracture), to a hallux rigidus or to a
sesamoid fracture.

UPPER EXTREMITY TRAUMA
SHOULDER GIRDLE
CLAVICLE FRACTURE: it could be medial, lateral or MEDIAL, the most common,
generally due to a compressive force from falling, is complete and generally with visible
heal.
SCAPULA FRACTURE: severe trauma that in 80% of times fractures the body or the
neck of the scapula. Usually patient presents other fractures and the Bankart type is the
glenoid avulsion from triceps.
HUMERUS FRACTURE:
- HILL-SACH'S: proximal to anatomic neck
- FLAP FRACTURE: the greater tuberosity may be avulsed or fractured by direct trauma
- SURGICAL NECK FRACTURE
- PROXIMAL SHAFT
DISLOCATIONS

GLENOHUMERAL DISLOCATIONS: classified into the direction in which the humeral
head has been displaced, the more commons are:
ANTERIOR GLENOHUMERAL JOINT DISLOCATION (95%) from forceful abduction
and external rotation.
POSTERIOR GLENOHUMERAL JOINT DISLOCATION (2-4%, very severe trauma case)
ACROMIOCLAVICULAR JOINT DISLOCATION (acromion goes inferiorly): bilaterally
weighted x-ray is done to find this dislocation, which classed is based on the degree of
injury to the acromioclavicular and coracoclavicular ligaments:
-type 1 (mild sprain): the acromioclavicular ligament is stretched but coracoclavicular are
intact. Conservative treatment.
-type 2 (moderate sprain): the AC ligament is torn and the coracoclavicular is stretched
but intact; the joint space is wider and elevation of clavicle may occur. Conservative
treatment or surgery.
-type 3 (severe sprain): the AC ligament and coracoclavicular ligaments are completely
torn; it present a clavicle elevation more than 5mm from the opposite side and a wider AC
joint space. Treatment may requires surgery.
ELBOW
OLECRANON FRACTURE: due to a direct blow or trauma to the olecranon or an acute
hyper flexion injury that causes avulsion from the triceps insertion. it's an intraarticular
fracture, distraction and separation may occur and often is required fixation.
FOREARM
NIGHTSTICK FRACTURE: usually single and non-comminuted fracture from direct
trauma to raised forearm with a stick.
WRIST
DISTAL RADIUS FRACTURES: more commons are classified for its injury mechanism in:
- COLLES FRACTURE: from fallen on outstretched arm with hand extended (posterior
angulation of radius).
- SMITH'S FRACTURE (or RESERSE COLLES' FRACTURE): from fallen on outstretched
arm with flexed hand (anterior angulation of radius)
CARPAL BONES
SCAPHOID FRACTURE: usually due to direct trauma in hyperextension and radial flexion
wrist, such as falling on an outstretched hand. It's the most common site of non-union
fractures, the most common site of occult fracture and a cause of avascular necrosis.
HAND
METACARPAL FRACTURE:
BOXER'S FRACTURE: transverse fracture of the neck of the 2nd and 3rd metacarpal,
common fracture site after a direct hit to the metacarpal phalangeal joints like a
straight or blow.
BAR ROOM FRACTURE: 4th and 5th metacarpal neck, common fracture site after a
direct hit to the metacarpal phalangeal joints, especially in inexperienced fighter.
12.
ARTHRITIDES

DEGENERATIVE JOINT DISEASES : non inflammatory, non uniform loss of joint space,
osteophytes, subchondral sclerosis, subchondral cysts (geodies) ,interarticular loose
bodies, joint subluxation, usually monoarticular and mostly asymmetric.
DEGENERATIVE SPINE DISEASE : target sites are C5-C7, T10-T12, L4-S1. The most
common diseases are:
- FACET JOINT OSTEOARTHROSIS: most frequent in cervical and lumbar spine
- UNCOVERTEBRAL OSTEOARTHROSIS (Von Luschka's joint arthrosis): cat ears should
be sharp in an AP projection; when they start to flatten on a side there is a
osteoarthrosis going on.
- DEGENERATIVE DISK DISEASE: a loss of disk space, osteophytes and sclerosis are
usually clear finding for these diseases, when there is foraminal encroachment, it can
cause an impingment to nerves, like in CERVICAL SPONDYLOSIS, and it's possible to
find an intercalary bone, like in ANNULAR OSSIFICATION, to don't get confused with a
fracture or a limbus bone. Often it's also present at least one bulging, that is an
indicator of degenerative disease
- SPONDYLOSIS AND SENILE KYPHOSIS
- COSTOVERTEBRAL ARTHROSIS
- DEGENERATIVE SPONDYLOLISTHESIS: degeneration that cause the break of pars
intraarticular joint and migration.
- DEGENERATIVE SCOLIOSIS: usually when an osteophyte on a vertebral body causes a
tilt of this, with relative stress and curve degeneration.
- BAASTRUP'S DISEASE or kissing spinous processes: usually seen in lateral projection,
there is an increase of stress in spinous process during extension.
- DEGENERATIVE SCLEROSIS: degeneration that increase ulterior the osteoplastic
formation .
- SACROILIAC JOINT DEGENERATION
DEGENERATIVE JOINT DISEASE OF THE EXTREMITIES: maybe more common that
in the spine; caused from repetitive movements especially:
- HIP OSTEOARTHROSIS: decrease of superior joint space is more common, often
surgery replacement for its possible complications.
- KNEE OSTEOARTHROSIS: usually medial where there is more stress from the weight,
with the presence of osteophytes in tibial spine, subchondral cysts and sclerosis as
indicators (AP weight-bearing x-ray). Patellar tooth sign could occurs.
- ANKLE AND FOOT: rare, generally after a trauma, when an enthesophyte became a
heel spurs.
-SHOULDER AND ELBOW: not very common, usually for a repetitive arm used or from an
osteophyte formation dues to a trauma.
- WRIST: usually metacarpal-trapezium joint
- HAND: visible nodes on finger, called HEBERDEN when they are present on DIP and
BOUCHARD when are in PIP.
-DISH: diffuse idiopathic skeletal hyperostosis, calcification of ligament that usually
occurs on cervical and lumbar spine; it seems an osteophytes formation, but is has more
than 3 continuous vertebral segments flowing connected.
- SYNOVIOCHONDROMETAPLASIA : intraarticular osteochondral bodies that causes
pain, crepitus, swelling especially in knee, hip, elbow and wrist (popcorn calcifications)

INFLAMMATORY ARTHRITIS
- RHEUMATOID ARTHRITIS: it's a severe destructive arthropathy, an inflammatory
process that occurs in joints spaces. The best indicators are in order : the positivity to
rheumatoid factor, bone erosions, uniform loss of joint space; frequently are bilateral
and symmetrical. There is also a juvenile form.The target sites are:
- hand: generally severe, it attacks more MCP and PIP. Typical deformations seen are
Boutonniere and Swan neck.
- wrist: the best indicators are ulnar styloid and/or carpal erosion, carpal deformity,
bony ankylosis and Terry Thomas sign.
- cervical spine: not very frequent but important for manual therapies because it causes
atlantoaxial instability and it presents erosions and narrowing.
- hip: uniform loss of joint space and erosion are great indicators, together with
bilateral acetabular protrusion (migration to femoral head medially).
- knee: uniform loss of joint space, erosions in bone corner and margin, subchondral cysts
and Baker's Cysts (in gastrocnemius muscle) are often presents.
- SERONEGATIVE SPONDYLOARTHROPATHIES: rheumatoid diseases that are
negative for the rheumatoid factor analysis. An example is ANKYLOSING
SPONDYLITIS, the fusion of joints, usually bilateral and symmetrical due to a synovial
inflammation. Sacroiliac fused joints are one of the most common causes for low back
pain in young/adult people.

METABOLIC JOINT DISEASES
- GOUT: it is a common arthritis induced by intra-articular deposits of sodium crystals
on cartilage and synovium that attack joint: swollen and crystals formation on x-ray are
typical indicator if the rheumatoid factor is positive. It's classified in 4 stages,
according with the gravity, from asymptomatic to chronic.