3 Cervical Spine (Lateral) Anterior arch of the atlas Dens of axisPosterior arch of the atlas Soft palateRoot of the tongue Transverse process Intervertebral disc Inferior articular process Superior articular process Zygapophyseal (facet) joint Spinous process of C72nd-7th: The bodies of 2nd to 7th cervical vertebrae
5 Anterior soft tissue swelling soft tissue swelling is indirect indicator of significant trauma, esp. when the soft tissue swelling is above the epiglottis;retropharyngeal soft tissue swelling should not exceed:anterior to C3 should not exceed 3 mm.if > than 5 mm at C3 consider minimally displaced C2 fracture;w/ children, crying increases the C3 distance;below C4 the thickness varies from 8 to 10 mm & is less reliable;
6 Anterior soft tissue swelling distance between tracheal air column & anterior aspect of vertebral body should be No greater than:Adults: no > than 7 mm at C2 or 22 mm at C6;Child: no > than 14 mm at C6during x-ray child should be in neutral or sl extension and w/ a full inspiration;fullness and laxity of child's prevertbral soft tissues may simulate traumatic swelling if film is obtained during expiration or flexion;
7 Spinal Laminal Lines Three curves to follow Anterior aspect of vertebral bodiesPosterior aspect of vertebral bodiesSpinolaminar lineAbnormalities in the curvesposterior malalignment is more significant than anterior because of proximity of the spinal cordspinal canal diameter is significantly narrowed if < 14 mmanterior subluxation is caused by facet dislocation< 50% of vertebral body width = unilateral dislocation> 50% of vertebral body width = bilateral dislocation
8 Lateral Findings Examine bones for symmetry May provide evidence of fractureAbnormal symmetry is often due to compressioncompression of > 40% of normal vertebral body height usually indicates a burst fracture with possibility of bone fragments in the spinal canalanterior compression may cause a teardrop shaped fracture
9 Cervical Spine (Lateral) Bifid spinous process of C3 Superimposed articular processes Uncinate processes Air filled trachea Transverse process of C7 Transverse process of T1 1st rib Clavicle4th-7th: The bodies of 4th to 7th cervical vertebrae
11 Odontoid View to evaluate: C1 (Jefferson), Dens, superior facets of C2 for evaluating dens fractures, body of C2, & rotary C1-C2 dislocations;mach lines - teeth, C1 arch;open mouth view, along w/ lateral view, will reveal fractures of the dens ;atlantoaxial articulation & integrity of dens and body of C2 are best seen on the odontoid view;
12 Odontoid Viewthis is most technically most difficult film to obtain as it requires patient to open his mouth as wide as possiblelateral masses of C1 should align over the lateral masses of C2;lateral displacement of masses of C1 w/ respect to C2 may indicate Jefferson or burst fracture of the Atlas;combined lateral mass displacement > 7 mm suggests that transverse ligament is torn;
13 Anatomy of C2C2 provides rotation at its superior articulation w/ C1, & limited flexion, tilt, & rotation at its inferior articulation w/ C3;body of C2 is the largest of the cervical vertebrae;superior articulations are on the lateral masses;superior projection of the odontoid is stabilized to the C1 ring by transverse and alar ligaments;
14 Anatomy of C2lateral masses of C2 have aperture for accepting transversing vertebral artery;axis is transverse vertebra w/ its superior articular facets located anterior and its inferior facets located posterior;prominent spinous process of C2 is palpable beneath of occiput;
16 Thoracic VertebraEach vertebra is composed of a body anteriorly and a neural arch posteriorlyThe arch encloses an opening, the vertebral foramen, which helps to form a canal in which the spinal cord is housed.Protruding from the posterior extreme of each neural arch is a spinous process and extending from the lateral edges of each arch are transverse processes.The parts of the neural arch between the spinous and transverse processes are known as the laminae and the parts of the arch between the transverse processes and the body are the pedicles.At the point where the laminae and pedicles meet, each vertebra contains two superior articular facets and two inferior articular facets.The pedicle of each vertebra is notched at its superior and inferior edges. Together the notches from two contiguous vertebra form an opening, the intervertebral foramen, through which spinal nerves pass
17 Thoracic Spine Spinous process Pedicles Intervertebral disc space Ribs Vertebral bodyNeural foramen
18 Lumbar VertebraLumbar vertebrae are characterized by massive bodies and robust spinous and transverse processes.Their articular facets are oriented somewhat parasagittally, which is thought to contribute the large range of anteroposterior bending possible between lumbar vertebrae.Lumbar vertebrae also contain small mammillary and accessory processes on their bodies.These bony protuberances are sites of attachment of deep back muscles
24 AP Pelvis Lateral part of the sacrum Pubic tubercle Lesser trochanter Gas in colonIliumSacroiliac jointIschial spineSuperior ramus of pubisInferior ramus of pubisIschial tuberosityObturator foramenIntertrochanteric crestPubic symphysisPubic tubercleLesser trochanterNeck of femurGreater trochanterHead of femurAcetabular fossaAnterior inferior iliac spineAnterior superior iliac spinePosterior inferior iliac spinePosterior superior iliac spineIliac crest
25 AP Hip Anterior superior iliac spine Ilium Anterior inferior iliac spinePelvic brimAcetabular fossaHead of femurFoveaSuperior ramus of pubisObturator foramenInferior ramus of pubisPubic symphysisIschiumLesser trochanterIntertrochanteric crestGreater trochanterNeck of femur
26 Lateral Hip Greater trochanter Intertrochanteric crest Lesser trochanterNeck of femurHead of femurAcetabular fossaSuperior ramus of pubisObturator foramenInferior ramus of pubisIschium
27 AP Knee Femur Patella Medial epicondyle of femur Lateral epicondyle of femurMedial condyle of femurLateral condyle of femurIntercondylar eminenceIntercondylar notchKnee jointLateral condyle of tibiaMedial condyle of tibiaTibiaFibula
28 Lateral Knee Femur Lateral condyle of femur Medial condyle of femur FabellaPatellaBase of patellaApex of patellaIntercondylar eminenceApex of fibulaFibulaTibiaTibial tuberosity
30 Lateral Ankle Fibula Tibia Ankle joint Promontory of tibia Trochlear surface of talusTalusPosterior tubercle of talusCalcaneusSustentaculum taliTarsal tunnelNavicularCuneiformsCuboid
31 Talar DomeThe talar dome should be scrutinised for a subtle indentation of the joint surface, or a small detached fragment.This is evidence of an osteochondral fracture.May be subtle, is often missed, but this injury is clinically significant.
33 Boehler’s AngleCompressive fractures occur after a fall from a height.Subtle fractures may only be identified by assessing Boehler’s angle.This angle is measured by drawing a line from the highest point of the posterior tuberosity to the highest midpoint, and a 2nd line from the highest midpoint to the highest point of the anterior process.The angle, posteriorly, should be >30 degrees.If there is flattening of the bone due to a fracture, this angle will be decreased, to <30 degrees.
42 AP Shoulder Clavicle Acromioclavicular joint Acromion Greater tubercle of humerusHead of humerusLesser tubercle of humerusSurgical neck of humerusCoracoid processGlenoid fossaShoulder jointLateral border of scapula
43 AP Elbow Lateral supracondylar ridge Medial supracondylar ridge Olecranon fossaMedial epicondyleLateral epicondyleCapitulumOlecranonTrochleaCoronoid process of ulnaProximal radioulnar jointHead of radiusNeck of radiusTuberosity of radiusUlna
44 Lateral Elbow Supracondylar ridge Trochlea Olecranon Trochlear notch Coronoid process of ulnaHead of radiusNeck of radiusTuberosity of radiusUlna
45 PA Wrist I-V: Metacarpals Trapezium Trapezoid Capitate Head of capitateHamateHook of hamateScaphoidLunateTriquetrumPisiformStyloid process of radiusHead of ulnaStyloid process of ulnaRadiocarpal jointDistal radioulnar joint
46 Lateral Wrist 1st metacarpal Metacarpals II-V Trapezium Tubercle of scaphoidLunateTriquetrumRadiocarpal jointDistal end of radiusDistal end of ulna
47 Rule of 11’s Radial length or height Radial length is measured on the PA radiograph as the distance between one line perpendicular to the long axis of the radius passing through the distal tip of the radial styloid. A second line intersects distal articular surface of ulnar head. This measurement averages mm.
48 Rule of 11’s Radial inclination or angle Radial inclination represents the angle between one line connecting the radial styloid tip and the ulnar aspect of the distal radius and a second line perpendicular to the longitudinal axis of the radius. The radial inclination ranges between 21｡ and 25｡. Loss of radial inclination will increase the load across the lunate.
49 Rule of 11’sRadial tilt Radial tilt is measured on a lateral radiograph. The radial tilt represents the angle between a line along the distal radial articular surface and the line perpendicular to the longitudinal axis of the radius at the joint margin.The normal volar tilt averages 11｡ and has a range of 2｡-20｡.
50 PA Hand Thumb Index Middle finger Ring finger Little finger I-V. Metacarpal bones1,4. Distal phalanx Middle phalanx 3,5. Proximal phalanx Sesamoid bonesDistal interphalangeal joint (DIP)Metacarpophalange al joint (V.)Carpometacarpal jointsTrapeziumTrapezoidCapitateHamateScaphoidLunateTriquetrumPisiformRadiusUlna