Nadia Quiz 2 Study.pdf

Bone density 4.3 Bone Remodeling and ABCs: B · architecture : contrast ·...

Bone density 4.3 Bone Remodeling and ABCs: B · architecture : contrast · texture : trabeculae B: Bone Density (1-3) #1 = Skeletal Architecture - general bone density: assess shade of grey looking for shades of grey implying sufficient radiographic contrast b/w bone & soft tissue & sufficient contrast w/in bone itself AKA: healthy bone and soft tissue can be clearly distinct from each other sureough Ex: Sufficient contrast in bone denser cortical shell (brighter) with less dense cancerous bone (less bright) ake meres cl ne normal bone heal= more radiodensity !! num thickness of margins bones loserzon wack the loser: It Osteomalacia: Rickets ↑ hypocalcification disorder can produce bone but cant calcify it wide porous bone radiologic finding: looser zone M arrow: radiolucent band transverse to cortex = stress fx bc demineralized cortex with increased radiodensity on either side bc bone trying to repair #2 Textural abnormalities look for changes in appearance of the trabeculae changes in mineralization result in change in appearance of trabeculae change in trabeculae = radiologic hallmark in diagnosis of disease process Descriptors used for trabeculae thin, delicate, smudge, fluffy Hyperparathyroidism decalcification of bones erosion of cortex tibia should have straight line = cortex - she squiggly = bad - texture inside is translucent = bad too Coley’s anemia inherited blood disorder = destruction of RBC metacarpals & phalanges - cortical thickening - osteopenia - marrow proliferation - all causes a loss of normal tubulation making the fingers look square or like sausages consider the lacy appearance of the inside of bones #3 local density changes assess for localized density changes - look for increases in bone density in WB areas (sclerosis) - look for excessive increases (excessive sclerosis) in OA conditions - look for reactive changes (reactive sclerosis) which occur when body acts to contain a diseased area Sclerosis normal increases in bone density in areas subjected to increased stress (wb jts) sign of repair extra bone to withstand the wb Excessive sclerosis can be normal: when bone heals it forms callus can be degenerative: arthritis/reactive sclerosis - reaction to tumor or cancer - lays down bone to surround the dx area Pic on L hallmark sign of arthritis - decreased medial jt space combined with sclerotic subchondral bone of medial tibial plateaus (oval) white part in oval - repair response to thinning of articular cartilage - spurs can also occcur Pic on R osteomyelitis on prox tibia reactive sclerosis trying to surround the infected area - really bright white parts white arrows on bottom showing draining effect to relieve pressure of pus on bone (dent) which is why the soft tissue enlarged C: Cartilage Spaces #1 Jt spaces asses the width of the jt spaces - is it well preserved with normal thickness of cartilage/disc/tissue if space is decreased - this is likely a result of degenerative changes Pic on L bands of fatty bone marrow parallel to L5 disk Pic on R hallmarks of degenerative disk dx at C5-C6 with narrow jt space & osteophyte formation @ vertebral end plates C: Cartilage #2 Subchondral bone assess the subchondral bone - look for changes in density/irregularities - Ex: sclerosis, OA subchondral bone becomes more sclerotic as new bone form to help WB - Ex: RA/Gout - little reactive sclerosis in subchondral bone, instead see erosion of subchondral bone in form of radiolucencies on jt margin (very transparent which isn’t normal for sclerosis) What is OA destructive jt dx that can result in - pain - stiffness - loss of ROM i - loss of activity tolerance tinci x-rays help identify jt space narrowing redneed - sclerosis almost always present (bright white) umum - can also have osteophyte formation to help WB - subchondral lucency bc focal loss of bone density C: Cartilage Spaces #3 Epiphyseal plates assess the epiphysis - look for changes in the position of the growth plate, size of the epiphyses, whether the borders are smooth & whether there is presence of disruption or gaps in the plates position of growth plate designated by relationship of ossified portion of secondary epiphysis to metaphysis is there a smooth margin, band of sclerosis - indicates increased bone activity associated with linear growth disruptions in growth plates from trauma or metabolic dx can be visualized & can be hard to dx bc need CL film for comparison Key idea for imaging: symmetry comparing one side to the other mmm  4.4 ABCs: Soft Tissue Salter- Harris Fx (left pic) fx thru the metaphysis, growth plate, and epiphysis triplanar fx normally happen at distal tibia brigherosis Normal radiograph of 8 y/o child borders of epiphysis normally bounded by smooth margin w/ sclerosis meaning increased bone activity Soft Tissues #1 Muscles assess the soft tissue of the muscles - look for changes in muscle girth that may represent muscle wasting or gross swelling of muscle and soft tissue gross muscle wasting = primary muscle disease paralysis or severe illness or disuse atrophy secondary to trauma Gross swelling: inflammation/edema/hemorrhage/tumor - looking at size/girth of muscle can be indicative of different pathologies Disuse atrophy of quadriceps this specific example secondary to a traumatic patellar dislocation shrunken concave of soft tissue outlining ⑧ the thigh Soft Tissues #2 Fat Pads assess the fat pads - look for changes in the position of fat pads, usually a result of swelling & possibly an injury to an adjacent structure look @ girth or location of soft tissue compared to the other extremity Lateral view pronator fat pad = thin radiolucent triangle w/ base attached to palmar surface of distal radius Right pic bowing bc fall/muscle strain/ inflammatory condition/ infxn/ septic arthritis bow is a result of fluid causing bulging in x-ray Soft tissue #3 jt capsule assess the jt capsule - usually you cant see these well, but become visible when swelling is present exacerbations of arthritic conditions like - infxn/hemophilia/acute jt trauma/ effusion from trauma & intrarticular fx can produce lipohemoarthrosis in jt capsule lipohemoarthrosis: mixture of fat & blood from marrow entering the jt space through osteochondral defect - fat less dense than blood it floats to surface of blood - aka on radiographs: fat fluid level or fat blood interface (FBI) - sign of potentially overlooked intraarticular fx FBI example marrow & blood seeping thru intra-articular tibial patella fx accumulated in suprapatellar area & divided into layers bc fluid density fx needs to happen in order to have FBI Make sure to recognize in this pic m densities to identify fat and blood interface look @ contour of skin being pushed out bc fluid accumulation Soft tissue #4 Periosteum assess the periosteum for any kind of reactive process - solid fxn from fx healing or osteomyelitis, laminated process due to repetitive injury, sunburst bc malignancy, or codmman’s triangle bc of tumor, hemorrhage or other trauma 4 different periosteal rxns - solid: indolent or slow rolling process (seen in fx healing, chronic osteomyelitis) - laminated/onion skin indicating repetitive injury Battered child syndrome associated w/ sarcomas - sunburst or speculated pattern - malignant bone lesions, metastatic squamous cell tumors appearance bc repeated breakthrough of tumor, neoplastic process, and new periosteal response Codman’s Triangle piece of periosteum elevated by abnormal conditions & ossifies in triangular shape can be seen in tumor or subperiosteal hemorrhage in battered child syndrome looks like something pushing the bone out making triangle shape - & - - these are the 4 periosteal rxns! - - Soft Tissues #5 Miscellaneous soft tissue findings assess for out of the ordinary soft tissue findings - gas as the result of gangrene or trauma, calcifications or foreign bodies gas in soft tissue: gas forming organisms like gangrene or trauma calcifications in soft tissue: old trauma where hemorrhage is coagulated & calcified - can also happen in vessels/organs - ex: renal calculi, gallstones, calcifications in abdominal organs can also see metal shards in soft tissue radiographs Myositis Ossificans hardwareneterotopic heterotrophic bone developed a  4.5 Skeletal Pathology - Categories, Distribution, Predictors Radiologic Diagnosis of Skeletal Pathology - Identify category of pathology - Identify distribution of lesion - Identify predictor variables that characterize disease features Identify Category - Congenital (Presence of cervical rib) - Inflammatory (Osteomyelitis, RA, gout) - Metabolic (Paget's Disease, Fibrous Dysplasia) - Neoplastic (Primary Bone Tumor) - Traumatic (Fractures) - Vascular (Avascular Necrosis) - - Miscellaneous or Other (MSK, Infection, OA) Inflammatory Category (Ankylosing Spondylitis) - 66 yr old man - Ossification of outer fibers of the disc - Amylose fibers & aphophyseal joints have fused - Takeaway, the amount of bone present in the pictures Metabolic Category (Nutritional Rickets) - Femoral Fracture in 3 yr old - - Fractures of both tibia & fibula - Right image is 2 yrs later - Diffuse osteopenia, Bowing, widened growth plates, Identify Distribution of Lesion - Monoarticular (Fracture) - Polyarticular (RA) - Diffuse (Osteoporosis, Metastases) Diffuse Distribution (Metastases) - - Wide Spread Sclerosis - Increased bone density, thoracic & lumbar appear sclerotic Identify Predictor Variables (Table 2-4) - Behavior of Lesion (Osteolytic, Osteoblastic, mixed) - Bone or Joint Involved - Locus, area, within bone - Age, Gender, Race of patient - Age can be risk factor for tumors - Margin of Lesion (Sharp or poorly defined) - Sharp is slow growing - Poor is more aggressive - Shape of Lesion (Long vs. Wide) - Longer is slow growing - Wide is more aggressive - Joint Space (Crossed or Preserved) - Bony Reaction - Periosteal reaction characterized by interuptted or uninterrupted - Interuptted is malignant or aggressive - Uninteruptted is benign - Matrix Production - Matrix is tissue produced by primary bone & neoplasms - Osteoid appears like white clouds (light density) - Conjoined appears more like popcorn * - Soft Tissue Changes - Edema, hemorrhage, joint effusion - History of Trauma or Surgery  4.6 The Radiologic Report Purposes of Radiologic Report - Link radiologic signs w/ patient history & exam findings - Provide comparison w/ earlier or later radiological exams - Permanent Record - Supports treatment through identified indications & contraindications for med intervention - Can be used in research - Facilitates communication - Typical Info - Patient demographics, imaging findings, conclusions, name of radiologist 4 D's - Basic Sequential tests performed - Detect - First thing radiologist needs to do - Much improved w/ information referral regarding patients history & exam findings - Describe - Findings are described clearly & concisely using medical terminology - Written for radiologist so another one can come to the same conclusion based on description only - Diagnosis or Differential Diagnosis - Heart of the report & the answer to the clinical question that referring provider is asking - Differentials are ordered in most likely sequence w/ max of 3 - Decision - What to do next, how important is it to inform others & how urgently - Is immediate communication required - Any more tests recommended? Example of Radiology Report Patient Friendly Revised Design - Explain medical terminology - Link locations on report w/ current complaints Errors in Diagnostic Radiology (Classification Renfrew) > - - Type 1 (Complacency) - Finding identified but attributed to wrong cause - Type 2 (Faulty Reasoning) - Finding identified as abnormal but atttributed to wrong cause - Type 3 (Lack of Knowledge) - Finding identified but attributed to wrong cause due to lack of knowledge - Type 4 (Under-Reading) - Missed abnormality that was appreciable in retrospect - Type 5 (Poor Communication) - Finding identifed as abnormal but poor communication to relevant clinician - Type 6 (Technique) - Abnormality was not identifiable secondart to poor technique - Type 7 (Prior Exam) - Failure to review previous imaging results in missed finding - Type 8 (History) - Finding missed due to incomplete clinical information D - Type 9 (Location) - Finding missed because it was outside of region of interest - Type 10 (Satisfaction of search) - Failure to find subsequent abnormality after intial abnormality was detected - Type 11 (Complication) - Most often interventional procedures - Type 12 (Satisfaction of Report) - Over reliance on prior report Errors in Diagnostic Radiology - Brooks Classification - Latent Errors - 'in built' system or technical faults that predispose to errors - Active Failures or Human error - Diagnostic errors or misinterpretation - Complications from procedures D - Can involve more than 1 person or be secondary to latent errors - External Causes - Beyond control of radiologist - Customer Causes - Related to patient & non-radiology staff  5.1 fractures and complications - fxs from trauma: - imaging of msk trauma typically involves x-ray - therapist should be aware of imaging performed at the emergency department (primary trauma survey) - primary trauma survey examples: - motor vehicle accident or fall may include: - cross-table lat of cervical spine to assess instability, fxs, or dislocations - ap view of chest to assess for hemothorax, pneumothorax, or pulmonary contusion - ap view of pelvis to assess fxs or hemorrhage - goal of primary trauma survey: - avoid multiple radiographic exams and quickly screen for life-threatening injuries - often involves a ct scan to reduce assessment time and decrease chance of missing a fx - fxs w serious complications: - fxs that can cause hemorrhage: pelvis or femur fxs - fxs that can cause fat embolism: multiple crushing injuries - fxs that cause neurovascular damage: spine, elbow, or proximal humerus fxs - orthopedic conditions may not be priority in major trauma, but fxs causing hemorrhage, fat embolism, or neurovascular damage require immediate tx - definition of a fx: - a fx is a break in the structural continuity of bone or cartilage - fxs are described using anatomic and standardized terms in radiology - eponyms (e.g., colles fx or boxer's fx) are avoided in radiologic descriptions due to their lack of precision - example: - fx’d ulna in ap view (often due to a blow to the forearm) - lat view reveals displaced head of radius - failure to recognize displacement can result in death of radial head and subsequent elbow dysfxn - importance of obtaining two views in an injury - closed vs open fx: - closed fx: skin and tissue overlying fracture are intact - open fx: skin is perforated or broken, regardless of wound size - distinction based on exposure to external environment - terms "simple" and "compound" are no longer used; replaced by "closed" and "open" in diagnostic terminology  5.2 Elements of a Fx 7 Elements of Fx anatomic site & extent of the fx type of fx, complete or incomplete alignment of the fx fragments direction of fx line special ft of the fx such as impaction or avulsion associated abnormalities, such as jt dislocation special types of fxs resulting from abnormal stress or pathological processes in the bone, such as stress fx or pathological fx #1 Anatomic site and extent of the fx know the parts of the femur fx can occur from extra-articular to intra-articular area intra-articular surface called this bc it’s inside the pelvis Top pic distal femur fx that’s intra-articular - intracondylar notch & medial condyle displaced medially/ inferiorly Bottom pic fx above the condyle alignment off #2 Type of fx complete, left, or incomplete, right complete: one bone becomes 2 fragments comminuted: more than one fragment incomplete: one cortical margin remains intact, only one bone fragment bc only one portion of cortex disrupted - relatively stable - may remain in position if stresses are minimized - normally in short bones, irregular bones, flat bones  incomplete pic can tell bc cortical margin still intact buckle fx of distal ulna with radial angulation complete pic complete transverse fx of distal right radial metadiaphysis w/ posterolateral displacement by one shaft width overall distal radioulnar jt alignment is preserved #3 Alignment of fx fragments Alignment position... 1 - based on pos of distal fragment in relation to prox fragment non displaced - some contact b/w fragments displaced - no contact just review this :) can still see where screws were after #4 Direction of fx lines described in reference to longitudinal axis of long bone transverse - bending force @ right angle to longitudinal axis longitudinal - force is parallel to shaft of bone oblique - compression and bending rotation - diagonal orientation spiral - spirals around long axis - rotational force - vertical segment with sharp jagged edges - heal faster than oblique bc fit better and more stable  oblique fx normally in oblique plane - prone to angulation (distal part of bone goes in dif dir) spiral fx - notice sharp edge segment - high energy trauma - associated with displacement Al #2 Segment Comminuted Fx fx with more than 2 fragments A: common - wedge shaped/butterfly shaped B: 2/3 segmented fx C: multiple fragments comminuted fxs due to extremely high energy loads ex: crushing forces, MVA #5 presence of special features Left: Impaction - compression compression forces commonly found - axial loading vertebrae Right: Avulsion tibia - tensile loading of bone at femur (can be driven down into attachment site tibia causing tibial plateau impaction fx) Avulsion bc achilles tendon pulled part of calcaneus up when fx un  know this about abnormalities!! : Swelling stress fx regular localized areas of more radio dense - ongoing attempt at repairing the bone initial imaging looks normal so hard to dx sometimes up to 6 weeks pathological fx bone weak bc pathological process - OP, pagers, osteogenesis imperfecta, tumor infxn, disuse periprosthetic fx occur inter-operatively or around the prosthetic components YEARS after sx - bone graft fx - spontaneous, 2-3 yrs after implantation, not related to trauma, occurrence: 40%, higher for ppl with plate hardware or ppl undergoing chemo L pic lucency of posterior superior calcaneal cortex calcaneus = common place for fx R pic transverse fx of radial shaft near jxn of proximal & mid third severe cortical thickening of bone bc constant WB (white and wide)  Area of lucency sclerotic bone more severe bc not as much turnover sporadic bone white bc active turnover Pathological fx osteogenesis imperfecta: abnormal maturation of collagen affecting both the intramembranous & endochondral bone formation distal third of olecranon diffuse decrease in bone density thin cortices and flared metastases & cystic appearance of prox ends of radius and ulna mushroom appearance Metastases L pic - bone scan showing metastatic lesion caused by breast cancer - increased uptake at injxn site and bladder bc gotta be excreted - other dark spot abnormal = cancerous lesion R pic - fx at prox femur bc tumor weakened it Periprosthetic fx he didn’t say much here  5.3 fx in children - salter- harris - fractures in children: - complicated by features resembling fractures, such as growth plates, secondary centers of ossification, and large nutrient foramina - comparison films of the uninvolved side are useful (symmetry helps with diagnosis) - immature bone: only ossified portions are imaged, preformed cartilage is not imaged - additional elements of fracture description in children: - incomplete shaft fractures - fractures of the epiphysis and epiphyseal plate - incomplete fractures in children 8C: 8C - greenstick fracture: incomplete fracture; shaft fractured on tension side, cortex and periosteum intact on compression side - torus fracture: impaction fracture resulting in cortical buckling, often at metaphyseal regions; occasionally seen in adults with underlying pathology - plastic bowing: longitudinal compression forces on curved growing bone exceed elastic capacity, resulting in permanent bowing; a type of incomplete fracture with microscopic fatigue lines - fractures of the epiphysis and epiphyseal plate 9C, D 9D: - salter-harris classification: - mnemonic: salter - type i (s): straight across (5% of fractures) - type ii (a): above (75% of fractures) - type iii (l): lower or below (10% of fractures) - type iv (t): two or through (10% of fractures) - type v (er): erasure or crush of growth plate (5% 9D or less of fractures) - higher classification indicates greater risk of complications and worse prognosis - example: salter-harris type ii fracture of distal tibia, fracture extends through growth plate and exits through metaphysis - healing of fractures in children: - divided into three phases: inflammatory (acute), reparative (subacute), and remodeling (chronic) - remodeling in children depends on: - skeletal age - distance of fracture from growth plate - severity of fragment displacement - children's fractures may not always remodel with optimal results depending on fracture type and growth plate impact  5.4 fx reduction - reduction and fixation of fractures: - reduction: restoration of displaced bone fragments to normal anatomic position - occurs via closed or open reduction - closed reduction: - no incisions made - use manipulation, traction, or both to guide fragments into place - often has a soft tissue pin between bone ends - open reduction: - surgical incision to expose fracture site - after reduction, fracture fragments kept in position through fixation - fixation: - method of maintaining fracture fragments in position after reduction to achieve healing - benefits: - immediate pain relief - promote healing over time - types of fixation: - external fixation: - plaster cast - splint - internal fixation: - pins - wires - plates - screws - rods - other hardware - orif (open reduction internal fixation): - combination of open reduction and internal fixation - examples of fixation: - plaster cast immobilizing distal radius fracture - internal fixation with plate and hardware for wrist arthrodesis (fusion technique to relieve pain and provide stability in advanced arthritis) D - combination of internal and external fixation with uniplanar external fixator for comminuted distal radius fracture and ulnar styloid fracture - orif of right radius after fall from ladder: - patient fell from 80 cm ladder - presented with right elbow pain and fracture dislocation of right radius - orif performed one day after initial presentation - fracture healing: - types of bone healing: - cortical bone healing: - formation of new bone or callus bridging fracture gap - hematoma fills fracture site after periosteum and endosteum rupture - bone deposition and creeping substitution - collar of callus surrounds fracture site, replaced by secondary callus - callus organized by mechanical stresses (wolff's law)  - cancellous bone healing: - unite with little or no callus formation D - direct osteoblastic activity at fracture site (creeping substitution) - inter-trabecular bone formation (e.g., drill hole in tibia) - occurs in vertebral compression fractures, distal radius fractures, tibial condyle fractures - membranous bone formation - requires close contact of fracture fragments - if approximation not achieved, hematoma fills gap and healing proceeds by callus formation - spatially restricted, slow or incomplete if gap > few mm - surgically compressed and fixated bone healing: - direct osteoblastic and osteoclastic activity - bone deposition and resorption occur simultaneously - example of fracture healing in a patient: - 17-year-old girl with tibia and fibula fractures: - image a: fracture fragments displaced laterally - image b: callus formation - image c: no fracture lines, residual callus - emergency room films after sledding accident: - fracture at junction of distal and middle thirds of tibia and fibula - fracture fragments overriding and displaced laterally, good alignment - follow-up after three weeks: callus bridging fracture gap (external fixation with plaster cast) - follow-up after one year: good remodeling, no fracture lines V